Information Collection

Authorization Form on behalf of Claimant under 42 CFR 83.7

IC 180186 under ICR 202511-0920-001 · OMB 0920-0639.

Documents and Forms

Document Name Document Type
Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Energy Employees for Addition to the Special Exposure Cohort Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Form 0920-0639 Special Exposure Cohort Petitioner Authorization Form_DEC2025 Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Authorization for Individual or Entity to Petition HHS o Attachment E Authorization Form 2019_09_20.pdf Form and Instruction
Authorization for Individual or Entity to Petition HHS o Attachment E Authorization Form 2019_09_20.pdf Form and Instruction
0920-0639 Special Exposure Cohort Petitioner Authorization Form_DE Attachment E SEC Authorization form.pdf Form and Instruction
0920-0639 Special Exposure Cohort Petitioner Authorization Form_DE Attachment E SEC Authorization form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization Form on behalf of Claimant under 42 CFR 83.7	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 83.7

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	Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Energy Employees for Addition to the Special Exposure Cohort	Attachment E Authorization Form 2019_09_20.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0639	Special Exposure Cohort Petitioner Authorization Form_DEC2025	Attachment E SEC Authorization form.pdf	N/A	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: 3	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	1	1

Documents for IC

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].