View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 1240-0057	ICR Reference No: 202201-1240-003
Status: Historical Active	Previous ICR Reference No: 201901-1240-008
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Application for Self-Insurance Under the Black Lung Benefits Act
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: 11/23/2022
	Date Received in OIRA: 07/11/2022
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2025	36 Months From Approved	11/30/2022
Responses	294	0	318
Time Burden (Hours)	261	0	283
Cost Burden (Dollars)	34,080	0	145

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	294	318	-24
Annual Time Burden (Hours)	261	283	-22
Annual Cost Burden (Dollars)	34,080	145	33,935

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: The estimated number of self-insure applicants has decreased from 53 to 49. The respondents estimated annualized value of the burden hours has decreased due to the number of applications for self-insurance received. Annual costs to respondents decreased because the number of applicants is lower.

Annual Cost to Federal Government: $15,866

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: Marcela Meneses 304 420-1232 meneses.marcela@dol.gov

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