OWCP Medical Bill Processing Questionnaire

Improving Customer Experience (OMB Circular A-11, Section 280 Implementation) for the Department of Labor (DOL)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1225-0093 can be found here:

Documents and Forms

Document Name Document Type
OWCP Medical Bill Processing Questionnaire Form and Instruction
OWCP Medical Bill Processing Questionnaire OWCP Medical Bill Processing Questionnaire_12.5.2023_Clean Copy.docx forms.office.com/r/QETPjc43mu Form and Instruction
OWCP Medical Bill Processing Questionnaire OWCP Medical Bill Processing Questionnaire_12.5.2023_Clean Copy.docx forms.office.com/r/QETPjc43mu Form and Instruction
ICR Template_A11 Section 280 Clearance - OWCP MBP Questionnaire_12.5.2023.docx A-11 Section 280 Coversheet IC Document
ICR Template_A11 Section 280 Clearance - OWCP MBP Questionnaire_12.5.2023.docx A-11 Section 280 Coversheet IC Document

Information Collection (IC) Details

IC Title:	OWCP Medical Bill Processing Questionnaire	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

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	N/A	OWCP Medical Bill Processing Questionnaire	OWCP Medical Bill Processing Questionnaire_12.5.2023_Clean Copy.docx	https://forms.office.com/r/QETPjc43mu	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
A-11 Section 280 Coversheet	ICR Template_A11 Section 280 Clearance - OWCP MBP Questionnaire_12.5.2023.docx	12/05/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.