Medical Travel Refund Request

Documents and Forms

Document Name Document Type
Form OWCP-957A Medical Travel Refund Request Form and Instruction
Form OWCP-957A Medical Travel Refund Request Form and Instruction
OWCP-957A Medical Travel Refund Request - Mileage OWCP-957A_20240104.pdf Form and Instruction
OWCP-957A Medical Travel Refund Request - Mileage OWCP-957A_20240104.pdf Form and Instruction
OWCP 957B Medical Travel Refund Request - Expenses OWCP-957B_20240104.pdf Form and Instruction
OWCP 957B Medical Travel Refund Request - Expenses OWCP-957B_20240104.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Travel Refund Request	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 725.406 20 CFR 30.404 20 CFR 10.315 20 CFR 725.701

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-957A	Medical Travel Refund Request - Mileage	OWCP-957A_20240104.pdf		Yes	No	Fillable Printable
Form and Instruction	OWCP 957B	Medical Travel Refund Request - Expenses	OWCP-957B_20240104.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1 (FECA)	FR Citation: 81 FR 47418

Number of Respondents: 37,132	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	356,875	356,875
Annual IC Time Burden (Hours)	53,531	53,531
Annual IC Cost Burden (Dollars)	239,106	239,106

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.