View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 1240-0028	ICR Reference No: 202101-1240-001
Status: Historical Active	Previous ICR Reference No: 201710-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Report of Changes That May Affect Your Black Lung Benefits
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/21/2021
	Date Received in OIRA: 02/17/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2024	36 Months From Approved	05/31/2021
Responses	12,000	0	26,000
Time Burden (Hours)	2,810	0	6,089
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	12,000	26,000	-14,000
Annual Time Burden (Hours)	2,810	6,089	-3,279
Annual Cost Burden (Dollars)	0	0	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: The total burden hours have decreased by 3,279 hours, from 6,089 to 2,810. This adjustment reflects a declining population of Part C beneficiaries. The option to submit the completed form online through the COAL Mine web portal was added to both forms.

Annual Cost to Federal Government: $107,215

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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