Medical Travel Refund Request Form

OMB Control No: 1240-0056	ICR Reference No: 201612-1240-006
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Medical Travel Refund Request Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule	Conclusion Date: 03/06/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/10/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This Information Collection Request (ICR) is being submitted to allow the public to comment on the Information Collection identified in the Notice of Proposed Rulemaking (NPRM) titled, Black Lung Benefits Act: Medical Benefit Payments. This information collection is normally cleared under control number 1240-0037; however, a separate ICR has already been submitted to OMB for review to extend the existing authorization. As the RegInfo.gov database can only accommodate one ICR per collection for OMB review, this ICR is submitted under a new control to satisfy administrative concerns and to meet the requirements set forth at 5 CFR 1320.11(b). The underlying information collection requirements remain unchanged; however, this ICR would revise the currently approved ICR to incorporate the regulatory updates proposed in the NPRM.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act    US Code: 5 USC 8101 Name of Law: Federal Employees’ Compensation Act    US Code: 42 USC 7348 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1240-AA11	Proposed rulemaking	82 FR 739	01/04/2017

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 739	01/04/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 739	01/04/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Medical Travel Refund Request

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information; however, it is submitted only out of administrative necessity to accommodate reginfo.gov system limitations ands avoid public confusion. An ICR covering the underlying information collection is currently under OMB consideration (see control number 1240-0037). The agency has submitted this ICR to provide a vehicle for public and OMB comment on the information collection requirements as stated in the proposed rule. The DOL intends to submit the final rule ICR under the regular control number.

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Yoon Ferguson 202 693-0701 [email protected]

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(i) Why the information is being collected;
			(ii) Use of information;
			(iii) Burden estimate;
			(iv) Nature of response (voluntary, required for a benefit, or mandatory);
			(v) Nature and extent of confidentiality; and
			(vi) Need to display currently valid OMB control number;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date: 01/10/2017

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