Information Collection

Medical Travel Refund Request

IC 38444 under ICR 201004-1240-010 · OMB 1240-0037.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0037 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-957 Medical Travel Refund Request Form and Instruction
OWCP-957 Medical Travel Refund Request OWCP-957.pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Travel Refund Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.315 20 CFR 30.404 20 CFR 725.406 20 CFR 725.701

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-957	Medical Travel Refund Request	OWCP-957.pdf	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 182,535	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	182,535	19,299	163,236
Annual IC Time Burden (Hours)	30,301	3,204	27,097
Annual IC Cost Burden (Dollars)	85,791	17,232	68,559

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.