OWCP Medical Bill Processing Questionnaire

Improving Customer Experience (OMB Circular A-11, Section 280 Implementation) for the Department of Labor (DOL)

Documents and Forms

Document Name Document Type
OWCP Medical Bill Processing Questionnaire Form and Instruction
OWCP Medical Bill Processing Questionnaire OWCP Medical Bill Processing Questionnaire_12.5.2023_Clean Copy.docx forms.office.com/r/QETPjc43mu Form and Instruction
ICR Template_A11 Section 280 Clearance - OWCP MBP Questionnaire_12.5.2023.docx A-11 Section 280 Coversheet IC Document

Information Collection (IC) Details

IC Title:	OWCP Medical Bill Processing Questionnaire	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	OWCP Medical Bill Processing Questionnaire	OWCP Medical Bill Processing Questionnaire_12.5.2023_Clean Copy.docx	https://forms.office.com/r/QETPjc43mu	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
A-11 Section 280 Coversheet	ICR Template_A11 Section 280 Clearance - OWCP MBP Questionnaire_12.5.2023.docx	12/05/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.