Information Collection

Request for State or Federal Workers' Compensation Information

IC 13703 under ICR 201306-1240-005 · OMB 1240-0032.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0032 can be found here:

Documents and Forms

Document Name Document Type
Form CM-905 Request for State or Federal Workers' Compensation Information Form
CM-905 Request for State or Federal Workers' Compensation Infor CM-905.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for State or Federal Workers' Compensation Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.535

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-905	Request for State or Federal Workers' Compensation Information	CM-905.doc		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/ESA-30	FR Citation: 67 FR 16878

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,000	600	1,400
Annual IC Time Burden (Hours)	500	150	350
Annual IC Cost Burden (Dollars)	980	322	658

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.