Information Collection

Miner's Claim For Benefits Under The Black Lung Act, Employment History, And Miner Medical Reimbursement Form

IC 121953 under ICR 198605-1215-006 · 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 UNDER THE BLACK LUNG ACT, EMPLOYMENT HISTORY, AND MINER MEDICAL REIMBURSEMENT FORM	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.	Available Electronically?	Can Be Submitted Electronically?
Form	CM-911,	No	No
Form	CM-911A,	No	No
Form	& CM-915	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	57,500	-114,500	172,000
Annual IC Time Burden (Hours)	20,834	-7,249	28,083
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.