View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 1240-0027	ICR Reference No: 202401-1240-010
Status: Historical Active	Previous ICR Reference No: 202304-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Survivor's Form for Benefits Under the Black Lung Benefits Act
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/01/2024
	Date Received in OIRA: 01/31/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2026	10/31/2026	10/31/2026
Responses	1,067	0	1,067
Time Burden (Hours)	142	0	142
Cost Burden (Dollars)	707	0	707

Annual Cost to Federal Government: $12,690

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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