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

Documents and forms in this information collection
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

IC Title:

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:

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	n/a				Yes	Yes	Fillable Fileable
Form and Instruction	0920-0639			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 %

table that charts list of burden
	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

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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