# Submission for OMB Review: Comment Request
The Department of Labor (DOL) has submitted the following public information collection requests (ICR) to the Office of Management and Budget (OMB) for review and approval in accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13, 44 U.S.C. chapter 35). A copy of each ICR, with applicable supporting documentation, may be obtained from RegInfo.gov at *http://www.reginfo.gov/public/do/PRAMain* or by contacting Darrin King on 202-693-4129 (this is not a toll-free number) / e-mail: *[email protected].*
Comments should be sent to Office of Information and Regulatory Affairs, Attn: OMB Desk Officer for the Employment Standards Administration (ESA), Office of Management and Budget, Room 10235, Washington, DC 20503, Telephone: 202-395-7316 / Fax: 202-395-6974 (these are not a toll-free numbers), within 30 days from the date of this publication in the *Federal Register* .
The OMB is particularly interested in comments which:
• 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:* Employment Standards Administration.
*Type of Review:* Extension without change of currently approved collection.
*Title:* Request for Employment Information.
*OMB Number:* 1215-0105.
*Frequency:* On occasion.
*Type of Response:* Reporting.
*Affected Public:* Private Sector: Business and other for-profit.
*Estimated Number of Respondents:* 500.
*Estimated Number of Annual Responses:* 500.
*Estimated Average Response Time:* 15 minutes.
*Estimated Total Annual Burden Hours:* 125.
*Total Annualized capital/startup costs:* $0.
*Total Annual Costs (operating/maintaining systems or purchasing services):* $210.
*Description:* This information collection is used to collect information about a claimant's employment. It is necessary to determine continued eligibility for compensation payments under the Federal Employees' Compensation Act (5 U.S.C. 8106).
*Agency:* Employment Standards Administration.
*Type of Review:* Extension without change of currently approved collection.
*Title:* Claim for Medical Reimbursement Form.
*OMB Number:* 1215-0193.
*Frequency:* On occasion and Annually.
*Type of Response:* Reporting.
*Affected Public:* Individuals or households.
*Estimated Number of Respondents:* 21,396.
*Estimated Number of Annual Responses:* 85,584.
*Estimated Average Response Time:* 10 minutes.
*Estimated Total Annual Burden Hours:* 14,207.
*Total Annualized capital/startup costs:* $0.
*Total Annual Costs (operating/maintaining systems or purchasing services):* $103,557.
*Description:* The Office of Workers' Compensation Programs (OWCP) administers the Federal Employees' Compensation Act, 5 U.S.C. 8101 *et seq.* , the Black Lung Benefits Act, 30 U.S.C. 901 *et seq.* , and the Energy Employees Occupational Illness Compensation Program Act of 2000, 42 U.S.C. 7384 *et seq.* All three statutes require OWCP to pay for covered medical treatment that is provided to beneficiaries, and also to reimburse beneficiaries for any out-of-pocket covered medical expenses they have paid. Form OWCP-915, Claim for Medical Reimbursement Form, is used for this purpose and collects the necessary beneficiary and medical provider data in a standard format. Beneficiaries must also attach billing information prepared by the medical provider (Form OWCP-1500 for professional medical services, Form OWCP-92 for institutional providers and hospitals, or a paper bill for prescription drugs dispensed by a pharmacy) and proof of payment.
Darrin A. King,
Acting Departmental Clearance Officer.