Information Collection

Claim for Medical Reimbursement Form

IC 38473 under ICR 201507-1240-005 · OMB 1240-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0007 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-915 Claim for Medical Reimbursement Form Form and Instruction
OWCP-915 Claim for Medical Reimbursement OWCP-915_revised.pdf www.dol.gov/esa/owcp/dfec/regs/complince/owcp-915.pdf Form and Instruction
FECA 20 CFR 10.802.pdf FECA 20 CFR10.802 IC Document
EEOICPA 30 CFR 30.702.pdf EEOICPA 20 CFR 30.702 IC Document
BLBA 20 CFR 725.701 and 725.705.pdf BLBA 20 CFR 725.701 and 20 CFR 725.705 IC Document
CFR-2015-title20-vol1-sec30-701 EEOICPA proposed.pdf EEOICPA 20 CFR 30.701 Proposed IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Medical Reimbursement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 30.702 20 CFR 10.802 20 CFR 725.705 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-915	Claim for Medical Reimbursement	OWCP-915_revised.pdf	http://www.dol.gov/esa/owcp/dfec/regs/complince/owcp-915.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)	FR Citation: 67 FR 16826

Number of Respondents: 10,632	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	38,480	12,608	25,872
Annual IC Time Burden (Hours)	6,388	2,094	4,294
Annual IC Cost Burden (Dollars)	68,879	26,190	42,689

Documents for IC

Title	Document	Date Uploaded
FECA 20 CFR10.802	FECA 20 CFR 10.802.pdf	10/24/2012
EEOICPA 20 CFR 30.702	EEOICPA 30 CFR 30.702.pdf	10/24/2012
BLBA 20 CFR 725.701 and 20 CFR 725.705	BLBA 20 CFR 725.701 and 725.705.pdf	10/24/2012
EEOICPA 20 CFR 30.701 Proposed	CFR-2015-title20-vol1-sec30-701 EEOICPA proposed.pdf	11/02/2015

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