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: 1240-0032	ICR Reference No: 201911-1240-002
Status: Historical Active	Previous ICR Reference No: 201607-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for State or Federal Workers' Compensation Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved	07/31/2020
Responses	6,000	0	2,000
Time Burden (Hours)	1,500	0	500
Cost Burden (Dollars)	3,480	0	1,000

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	6,000	2,000	4,000
Annual Time Burden (Hours)	1,500	500	1,000
Annual Cost Burden (Dollars)	3,480	1,000	2,480

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: Minor changes have been made to CM-905. Description of changes: Eliminated requirement for the miner’s full social security number and requiring only the last four digits, added two options to file this form (mail or electronically submit through the COAL Mine Portal), provided updated language for the Privacy Act Statement, and provided updated language for the Notice.The revisions to the form do not impact burden or respondent cost. The increase in burden due to agency estimate was a result of an estimated increase in the number of respondents.

Annual Cost to Federal Government: $66,030

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. 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? No

Agency Contact: Debbie Thurston 202 693-0913 Thurston.Debra@dol.gov