Information Collection

Petitioner Submission Format other than Form B 42 CFR 83.9

IC 180184 under ICR 202511-0920-001 · OMB 0920-0639.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment D1 SEC Form B Instructions 2019_09_20.pdf	Instruction
Attachment D1 SEC Form B Instructions 2019_09_20.pdf	Instruction
Attachment D2 example of petition without Form B.pdf	Other-Example of Petition without Fo
Attachment D2 example of petition without Form B.pdf	Other-Example of Petition without Fo

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 83.9

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
Instruction					Yes	Yes	Fillable Fileable
Other-Example of Petition without Form B					Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program

FR Citation: 68 FR 55962

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	44	44

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.

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