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OMB Control No: 1240-0027	ICR Reference No: 202603-1240-004
Status: Received in OIRA	Previous ICR Reference No: 202402-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Survivor's Form for Benefits Under the Black Lung Benefits Act
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 09/29/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	1,080	1,067
Time Burden (Hours)	144	142
Cost Burden (Dollars)	807	707

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	1,080	1,067	13
Annual Time Burden (Hours)	144	142	2
Annual Cost Burden (Dollars)	807	707	100

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: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents increased from 1,067 to 1,080. The number of respondents increased due to an increase in claims filed. The following estimates also increased due to an increase in number of forms received/responses. Responses: Responses have increased from 1,067 to 1,080. Burden Hours: Burden hours have increased from 142 to 144. Costs: Annual burden costs have increased from $707.00 to $807.00.

Annual Cost to Federal Government: $13,978

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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