REQUEST FOR STATE OR FEDERAL WORKERS' COMPENSATION INFORMATION

ICR 197808-1215-012

OMB: 1215-0060

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1215-0060 197808-1215-012
Historical Active 197410-1215-002
DOL/ESA
REQUEST FOR STATE OR FEDERAL WORKERS' COMPENSATION INFORMATION
Revision of a currently approved collection   No
Regular
Approved without change 09/06/1978
Retrieve Notice of Action (NOA) 08/17/1978
  Inventory as of this Action Requested Previously Approved
09/30/1983 09/30/1983 08/31/1979
15,000 0 15,000
2,000 0 2,000
0 0 0

REPORT IS A REQUEST TO A STATE OR FEDERAL WORKSRS' COMPENSATION PROGRAM FOR INFORMATION RELATIVE TO A BLACK LUNG BENEFITS AWARD, IF ANY, GRANTED BY SUCH PROGRAMS. (30 CFR 901)

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR STATE OR FEDERAL WORKERS' COMPENSATION INFORMATION CM-905

  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 15,000 15,000 0 0 0 0
Annual Time Burden (Hours) 2,000 2,000 0 0 0 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.
08/17/1978


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