81 FR 8994 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; Claim for Medical Reimbursement Form

DEPARTMENT OF LABOR
Office of the Secretary

Federal Register Volume 81, Issue 35 (February 23, 2016)

Page Range		8994-8994
FR Document		2016-03761

The Department of Labor (DOL) is submitting the Office of Workers' Compensation Programs (OWCP) sponsored information collection request (ICR) titled, ``Claim for Medical Reimbursement Form,'' to the Office of Management and Budget (OMB) for review and approval for continued use, without change, in accordance with the Paperwork Reduction Act of 1995 (PRA), 44 U.S.C. 3501 et seq. Public comments on the ICR are invited.

Federal Register, Volume 81 Issue 35 (Tuesday, February 23, 2016)

[Federal Register Volume 81, Number 35 (Tuesday, February 23, 2016)]
[Notices]
[Page 8994]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-03761]



[[Page 8994]]

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DEPARTMENT OF LABOR

Office of the Secretary


Agency Information Collection Activities; Submission for OMB 
Review; Comment Request; Claim for Medical Reimbursement Form

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: The Department of Labor (DOL) is submitting the Office of 
Workers' Compensation Programs (OWCP) sponsored information collection 
request (ICR) titled, ``Claim for Medical Reimbursement Form,'' to the 
Office of Management and Budget (OMB) for review and approval for 
continued use, without change, in accordance with the Paperwork 
Reduction Act of 1995 (PRA), 44 U.S.C. 3501 et seq. Public comments on 
the ICR are invited.

DATES: The OMB will consider all written comments that agency receives 
on or before March 24, 2016.

ADDRESSES: A copy of this ICR with applicable supporting documentation; 
including a description of the likely respondents, proposed frequency 
of response, and estimated total burden may be obtained free of charge 
from the RegInfo.gov Web site at http://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=201601-1240-006 or by contacting Michel Smyth by 
telephone at 202-693-4129, TTY 202-693-8064, (these are not toll-free 
numbers) or by email at [email protected].
    Submit comments about this request by mail or courier to the Office 
of Information and Regulatory Affairs, Attn: OMB Desk Officer for DOL-
OWCP, Office of Management and Budget, Room 10235, 725 17th Street NW., 
Washington, DC 20503; by Fax: 202-395-5806 (this is not a toll-free 
number); or by email: [email protected]. Commenters are 
encouraged, but not required, to send a courtesy copy of any comments 
by mail or courier to the U.S. Department of Labor-OASAM, Office of the 
Chief Information Officer, Attn: Departmental Information Compliance 
Management Program, Room N1301, 200 Constitution Avenue NW., 
Washington, DC 20210; or by email: [email protected].

FOR FURTHER INFORMATION CONTACT: Michel Smyth by telephone at 202-693-
4129, TTY 202-693-8064, (these are not toll-free numbers) or by email 
at [email protected].

SUPPLEMENTARY INFORMATION: This ICR seeks to extend PRA authority for 
the Claim for Medical Reimbursement Form information collection. Form 
OWCP-915 is used to claim reimbursement for out-of-pocket covered 
medical expenses paid by a beneficiary and must be accompanied by 
required billing data elements (prepared by the medical provider) and 
by proof of payment by the beneficiary. Federal Employees Compensation 
Act section 9, Black Lung Benefits Act section 413, and Energy 
Employees Occupational Illness Compensation Program Act of 2000 section 
3629(c), authorize this information collection. See 5 U.S.C. 8103, 30 
U.S.C. 936, and 42 U.S.C. 7384t.
    This information collection is subject to the PRA. A Federal agency 
generally cannot conduct or sponsor a collection of information, and 
the public is generally not required to respond to an information 
collection, unless it is approved by the OMB under the PRA and displays 
a currently valid OMB Control Number. In addition, notwithstanding any 
other provisions of law, no person shall generally be subject to 
penalty for failing to comply with a collection of information that 
does not display a valid Control Number. See 5 CFR 1320.5(a) and 
1320.6. The DOL obtains OMB approval for this information collection 
under Control Number 1240-0007.
    OMB authorization for an ICR cannot be for more than three (3) 
years without renewal, and the DOL seeks to extend PRA authorization 
for this information collection for three (3) more years, without any 
change to existing requirements. The DOL notes that existing 
information collection requirements submitted to the OMB receive a 
month-to-month extension while they undergo review. For additional 
substantive information about this ICR, see the related notice 
published in the Federal Register on August 17, 2015 (80 FR 49279).
    Interested parties are encouraged to send comments to the OMB, 
Office of Information and Regulatory Affairs at the address shown in 
the ADDRESSES section within thirty (30) days of publication of this 
notice in the Federal Register. In order to help ensure appropriate 
consideration, comments should mention OMB Control Number 1240-0007. 
The OMB is particularly interested in comments that:
     Evaluate whether the proposed collection of information is 
necessary for the proper performance of the functions of the agency, 
including whether the information will have practical utility;
     Evaluate the accuracy of the agency's estimate of the 
burden of the proposed collection of information, including the 
validity of the methodology and assumptions used;
     Enhance the quality, utility, and clarity of the 
information to be collected; and
     Minimize the burden of the collection of information on 
those who are to respond, including through the use of appropriate 
automated, electronic, mechanical, or other technological collection 
techniques or other forms of information technology, e.g., permitting 
electronic submission of responses.
    Agency: DOL-OWCP.
    Title of Collection: Claim for Medical Reimbursement Form.
    OMB Control Number: 1240-0007.
    Affected Public: Individuals or Households.
    Total Estimated Number of Respondents: 10,632.
    Total Estimated Number of Responses: 38,480.
    Total Estimated Annual Time Burden: 6,388 hours.
    Total Estimated Annual Other Costs Burden: $68,879.

    Authority: 44 U.S.C. 3507(a)(1)(D).

    Dated: February 12, 2016.
Michel Smyth,
Departmental Clearance Officer.
[FR Doc. 2016-03761 Filed 2-22-16; 8:45 am]
BILLING CODE 4510-CRX-P

8994 Federal Register / Vol. 81, No. 35 / Tuesday, February 23, 2016 / Notices

DEPARTMENT OF LABOR information collection. Form OWCP– including the validity of the
915 is used to claim reimbursement for methodology and assumptions used;
Office of the Secretary out-of-pocket covered medical expenses • Enhance the quality, utility, and
paid by a beneficiary and must be clarity of the information to be
Agency Information Collection accompanied by required billing data collected; and
Activities; Submission for OMB elements (prepared by the medical • Minimize the burden of the
Review; Comment Request; Claim for provider) and by proof of payment by collection of information on those who
Medical Reimbursement Form the beneficiary. Federal Employees are to respond, including through the
ACTION: Notice. Compensation Act section 9, Black Lung use of appropriate automated,
Benefits Act section 413, and Energy electronic, mechanical, or other
SUMMARY: The Department of Labor Employees Occupational Illness technological collection techniques or
(DOL) is submitting the Office of Compensation Program Act of 2000 other forms of information technology,
Workers’ Compensation Programs section 3629(c), authorize this e.g., permitting electronic submission of
(OWCP) sponsored information information collection. See 5 U.S.C. responses.
collection request (ICR) titled, ‘‘Claim 8103, 30 U.S.C. 936, and 42 U.S.C. Agency: DOL–OWCP.
for Medical Reimbursement Form,’’ to 7384t. Title of Collection: Claim for Medical
the Office of Management and Budget This information collection is subject Reimbursement Form.
(OMB) for review and approval for to the PRA. A Federal agency generally OMB Control Number: 1240–0007.
continued use, without change, in cannot conduct or sponsor a collection Affected Public: Individuals or
accordance with the Paperwork of information, and the public is Households.
Reduction Act of 1995 (PRA), 44 U.S.C. generally not required to respond to an Total Estimated Number of
3501 et seq. Public comments on the information collection, unless it is Respondents: 10,632.
ICR are invited. approved by the OMB under the PRA Total Estimated Number of
DATES: The OMB will consider all and displays a currently valid OMB Responses: 38,480.
written comments that agency receives Control Number. In addition, Total Estimated Annual Time Burden:
on or before March 24, 2016. notwithstanding any other provisions of 6,388 hours.
ADDRESSES: A copy of this ICR with
law, no person shall generally be subject Total Estimated Annual Other Costs
applicable supporting documentation; to penalty for failing to comply with a Burden: $68,879.
including a description of the likely collection of information that does not
Authority: 44 U.S.C. 3507(a)(1)(D).
respondents, proposed frequency of display a valid Control Number. See 5
CFR 1320.5(a) and 1320.6. The DOL Dated: February 12, 2016.
response, and estimated total burden
may be obtained free of charge from the obtains OMB approval for this Michel Smyth,
RegInfo.gov Web site at http:// information collection under Control Departmental Clearance Officer.
www.reginfo.gov/public/do/ Number 1240–0007. [FR Doc. 2016–03761 Filed 2–22–16; 8:45 am]
OMB authorization for an ICR cannot
PRAViewICR?ref_nbr=201601-1240-006 BILLING CODE 4510–CRX–P
be for more than three (3) years without
or by contacting Michel Smyth by
renewal, and the DOL seeks to extend
telephone at 202–693–4129, TTY 202– PRA authorization for this information
693–8064, (these are not toll-free DEPARTMENT OF LABOR
collection for three (3) more years,
numbers) or by email at DOL_PRA_ without any change to existing Office of the Secretary
PUBLIC@dol.gov. requirements. The DOL notes that
Submit comments about this request Agency Information Collection
existing information collection
by mail or courier to the Office of Activities; Submission for OMB
requirements submitted to the OMB
Information and Regulatory Affairs, Review; Comment Request; Uniform
receive a month-to-month extension
Attn: OMB Desk Officer for DOL– Billing Form
while they undergo review. For
OWCP, Office of Management and
additional substantive information
Budget, Room 10235, 725 17th Street ACTION: Notice.
about this ICR, see the related notice
NW., Washington, DC 20503; by Fax:
published in the Federal Register on SUMMARY: The Department of Labor
202–395–5806 (this is not a toll-free
August 17, 2015 (80 FR 49279). (DOL) is submitting the Office of
number); or by email: OIRA_ Interested parties are encouraged to
submission@omb.eop.gov. Commenters Workers’ Compensation Programs
send comments to the OMB, Office of
are encouraged, but not required, to (OWCP) sponsored information
Information and Regulatory Affairs at
send a courtesy copy of any comments collection request (ICR) titled, ‘‘Uniform
the address shown in the ADDRESSES
by mail or courier to the U.S. Billing Form,’’ to the Office of
section within thirty (30) days of
Department of Labor-OASAM, Office of Management and Budget (OMB) for
publication of this notice in the Federal
the Chief Information Officer, Attn: review and approval for continued use,
Register. In order to help ensure
Departmental Information Compliance without change, in accordance with the
appropriate consideration, comments
Management Program, Room N1301, Paperwork Reduction Act (PRA) of 1995
should mention OMB Control Number
200 Constitution Avenue NW., (44 U.S.C. 3501 et seq.). Public
1240–0007. The OMB is particularly
Washington, DC 20210; or by email: comments on the ICR are invited.
interested in comments that:
DOL_PRA_PUBLIC@dol.gov. • Evaluate whether the proposed DATES: The OMB will consider all
FOR FURTHER INFORMATION CONTACT: written comments that agency receives
mstockstill on DSK4VPTVN1PROD with NOTICES

collection of information is necessary
Michel Smyth by telephone at 202–693– for the proper performance of the on or before March 24, 2016.
4129, TTY 202–693–8064, (these are not functions of the agency, including ADDRESSES: A copy of this ICR with
toll-free numbers) or by email at DOL_ whether the information will have applicable supporting documentation;
PRA_PUBLIC@dol.gov. practical utility; including a description of the likely
SUPPLEMENTARY INFORMATION: This ICR • Evaluate the accuracy of the respondents, proposed frequency of
seeks to extend PRA authority for the agency’s estimate of the burden of the response, and estimated total burden
Claim for Medical Reimbursement Form proposed collection of information, may be obtained free of charge from the

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Document Created: 2018-02-02 14:33:34
Document Modified: 2018-02-02 14:33:34

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Notices
Action		Notice.
Dates		The OMB will consider all written comments that agency receives on or before March 24, 2016.
Contact		Michel Smyth by telephone at 202-693- 4129, TTY 202-693-8064, (these are not toll-free numbers) or by email at [email protected]
FR Citation		81 FR 8994

81 FR 8994 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; Claim for Medical Reimbursement Form

DEPARTMENT OF LABOROffice of the Secretary

Federal Register Volume 81, Issue 35 (February 23, 2016)

DEPARTMENT OF LABOR
Office of the Secretary