MINER'S CLAIM FOR BENEFITS AND EMPLOYMENT HISTORY

ICR 197807-1215-002

OMB: 1215-0052

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
121950 Migrated
ICR Details
1215-0052 197807-1215-002
Historical Active 197609-1215-003
DOL/ESA
MINER'S CLAIM FOR BENEFITS AND EMPLOYMENT HISTORY
Revision of a currently approved collection   No
Regular
Approved without change 07/27/1978
Retrieve Notice of Action (NOA) 07/25/1978
  Inventory as of this Action Requested Previously Approved
04/30/1983 04/30/1983 01/31/1979
110,000 0 40,000
73,333 0 40,000
0 0 0



None
None


No

1
IC Title Form No. Form Name
MINER'S CLAIM FOR BENEFITS AND EMPLOYMENT HISTORY CM-911 &, 911A

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 110,000 40,000 0 0 70,000 0
Annual Time Burden (Hours) 73,333 40,000 0 0 33,333 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/25/1978


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