Information Collection

EE-22 (General Medical Authorization Request)

IC 243774 under ICR 202503-1240-002 · OMB 1240-0060.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0060 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EE-22 EE-22 (General Medical Authorization Request)	Form and Instruction
Form EE-22 General Medical Authorization Request EE-22 (General Medical Authorization Request)	Form and Instruction
EE-22 General Medical Authorization Request EE-22 (General Medical Authorization Request) (11).docx owcpmed.dol.gov/	Form and Instruction
EE-22 General Medical Authorization Request EE-22 (General Medical Authorization Request) (11).docx owcpmed.dol.gov/	Form and Instruction

IC Title:

EE-22 (General Medical Authorization Request)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 30.400(a) 20 CFR 30.700

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EE-22			https://owcpmed.dol.gov/	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: DOL/OWCP-11

FR Citation: 81 FR 25765

Number of Respondents: 1,500

Number of Respondents for Small Entity: 393

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].