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View ICR - OIRA Conclusion

OMB Control No: 1240-0034	ICR Reference No: 202409-1240-002
Status: Active	Previous ICR Reference No: 202401-1240-009
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Authorization for Release of Medical Information for Black Lung Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/14/2025
	Date Received in OIRA: 12/12/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2028	36 Months From Approved	03/31/2025
Responses	5,990	0	5,000
Time Burden (Hours)	1,995	0	417
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	5,990	5,000	990
Annual Time Burden (Hours)	1,995	417	1,578
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Respondents: The number of respondents increased from 5,000 to 5,990. The following also increased due to an increased in number of respondents. Responses: Responses have increased from 5,000 to 5,990. Burden Hours: Burden hours have increased from 417 to 1,995. The current version of the CM-936 requested information from a single medical provider. The revised form, however, accommodates information from up to four providers. As a result, DCMWC anticipates that completing the form may take up to four times longer than before. Consequently, the Public Burden Statement has been adjusted to reflect this increase, with the estimated completion time now averaging 20 minutes, up from the previous average of 5 minutes. Costs: No other cost reported for this collection.

Annual Cost to Federal Government: $8,865

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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