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OMB Control No: 1240-0038	ICR Reference No: 202603-1240-005
Status: Received in OIRA	Previous ICR Reference No: 202402-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
Type of Information Collection: Revision 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	10,800	10,020
Time Burden (Hours)	9,450	8,768
Cost Burden (Dollars)	3,137	2,420

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	10,800	10,020	780
Annual Time Burden (Hours)	9,450	8,768	682
Annual Cost Burden (Dollars)	3,137	2,420	717

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 5,010 to 5,400. The number of respondents increased due to an increase in claims filed. Responses: Responses have increased from 10,020 to 10,800 due to an increase in number of forms received/responses. Burden Hours: Burden hours have increased from 8,768 to 9,450 due to an increase in number of forms received/responses. Costs: Annual burden costs have increased from $2,420 to $3,137 due to an increase in postage. Other changes not affecting burden estimates: It is the program’s discretion to make a few changes to the CM-911a necessary to obtain the specific mine site the miner worked at. Question #10 a and question #16.

Annual Cost to Federal Government: $264,627

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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