Information Collection

Miner's Claim For Benefits And Employment History

IC 121950 under ICR 197807-1215-002 · OMB 1215-0052.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	MINER'S CLAIM FOR BENEFITS AND EMPLOYMENT HISTORY	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-911 &				No	No
Form	911A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 110,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	110,000	70,000	40,000
Annual IC Time Burden (Hours)	73,333	33,333	40,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.