Information Collection

EEOICP Forms for Private Sector

IC 178683 under ICR 202605-1240-003 · OMB 1240-0002.

Documents and Forms

Document Name Document Type
Form EE-7 Medical requirements EEOICP Forms for Private Sector Form
Form EE-17B Physician Certification of Medical Necessity under the EEOICPA EEOICP Forms for Private Sector Form and Instruction
EE-7 Medical requirements Draft EE-7.docx Form
EE-17B Physician Certification of Medical Necessity under the E EE-17B.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EEOICP Forms for Private Sector	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.415 through 30.417 20 CFR 30.215 20 CFR 30.106 20 CFR 30.103 20 CFR 30.905 20 CFR 30.232 (a) and (b) 20 CFR 30.207 20 CFR 30.907 20 CFR 30.222

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	EE-7	Medical requirements	Draft EE-7.docx		Yes	No	Printable Only
Form and Instruction	EE-17B	Physician Certification of Medical Necessity under the EEOICPA	EE-17B.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-11	FR Citation: 81 FR 25868

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	1,185	1,185

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.

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