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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1240-0038
ICR Reference No:
201405-1240-005
Status:
Historical Active
Previous ICR Reference No:
201107-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
01/23/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/22/2014
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2018
36 Months From Approved
01/31/2015
Responses
11,000
0
9,500
Time Burden (Hours)
7,750
0
6,667
Cost Burden (Dollars)
2,058
0
1,771
Abstract:
CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and this form is completed by all applicants, both miners and survivors.
Authorizing Statute(s):
US Code:
30 USC 901
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
79 FR 29218
05/21/2014
30-day Notice:
Federal Register Citation:
Citation Date:
79 FR 63169
10/22/2014
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History
CM-911, CM-911A
Miner's Claim for Benefits Under the Black Lung Benefits Act
,
Employment History
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
11,000
9,500
0
0
1,500
0
Annual Time Burden (Hours)
7,750
6,667
0
0
1,083
0
Annual Cost Burden (Dollars)
2,058
1,771
0
0
287
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
There has been an increase for the Federal cost due to a postage rate increase. In addition, the Federal cost has increased due to an increase in claims filed for black lung, because of mine closures and outreach efforts. While not expected to affect respondent burden, this ICR has been classified as a revision because of minor changes to the forms. The changes clarify certain sections so claimants can better understand what information to provide. The OWCP has also incorporated a notice that informs persons with disabilities how they may request assistance to complete the information collection.
Annual Cost to Federal Government:
$210,130
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Debbie Thurston 202 693-0913 Thurston.Debra@dol.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
10/22/2014
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