Information Collection

Intake Form

IC 210150 under ICR 201712-3206-004 · OMB 3206-0263.

Documents and Forms

Document Name Document Type
Form OPM 1840 Intake Form Form and Instruction
OPM 1840 External Review Intake Form opm1840.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OPM 1840	External Review Intake Form	opm1840.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: OPM Central 19	FR Citation: 78 FR 65011

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-800	800
Annual IC Time Burden (Hours)	-800	800
Annual IC Cost Burden (Dollars)	0	0

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.