Information Collection

Black Lung Program Provider Information And Determination Physician Forms

IC 122250 under ICR 198205-1215-002 · OMB 1215-0137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0137 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	BLACK LUNG PROGRAM PROVIDER INFORMATION AND DETERMINATION PHYSICIAN FORMS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-1168,				No	No
Form	CM-1169				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,740	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,740	10,740
Annual IC Time Burden (Hours)	1,686	1,686
Annual IC Cost Burden (Dollars)	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.