View Information Collection Request (ICR) Package

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: 1240-0027	ICR Reference No: 201911-1240-004
Status: Historical Active	Previous ICR Reference No: 201607-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Survivor's Form for Benefits Under the Black Lung Benefits Act
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: 10/13/2020
	Date Received in OIRA: 03/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2023	36 Months From Approved	10/31/2020
Responses	850	0	1,100
Time Burden (Hours)	113	0	147
Cost Burden (Dollars)	377	0	450

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	850	1,100	-250
Annual Time Burden (Hours)	113	147	-34
Annual Cost Burden (Dollars)	377	450	-73

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Fewer CM-912 forms completed. Privacy Act Notice and address where to mail completed form was added to this ICR

Annual Cost to Federal Government: $11,796

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. Yes

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. Yes

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

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