1) COMPARABILITY OF CURRENT WORK TO COAL MINE EMPLOYMENT 2) COAL MINE EMPLOYMENT AFFIDAVIT 3) AFFIDAVIT OF DECEASED MINER'S CONDITION

ICR 198702-1215-008

OMB: 1215-0056

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0056 198702-1215-008
Historical Active 198403-1215-001
DOL/ESA
1) COMPARABILITY OF CURRENT WORK TO COAL MINE EMPLOYMENT 2) COAL MINE EMPLOYMENT AFFIDAVIT 3) AFFIDAVIT OF DECEASED MINER'S CONDITION
Revision of a currently approved collection   No
Regular
Approved without change 04/20/1987
Retrieve Notice of Action (NOA) 02/25/1987
  Inventory as of this Action Requested Previously Approved
03/31/1990 03/31/1990 03/31/1987
14,000 0 22,500
5,084 0 7,500
0 0 0

FORMS ARE USED TO HELP DETERMIN ELIGIBILITY FOR BENEFITS: 1) CM-913 IS COMPLETED BY BENEFICIARIES AND COMPARES NON-COAL MINE WORK TO COAL MINE WORK, 2) CM-918 IS COMPLETED BY PEOPLE WITH DIRECT KNOWLEDGE OF MINER'S COAL MINE WORK TO SUPPLEMENT EVIDENCE, AND 3) CM-1093 IS COMPLETED BY PEOPLE WITH DIRECT KNOWLEDGE OF THE DECEASED MINER'S MEDICAL CONDITION ONLY IF MEDICAL EVIDENCE IS INSUFFICIENT.

None
None


No

1
IC Title Form No. Form Name
1) COMPARABILITY OF CURRENT WORK TO COAL MINE EMPLOYMENT 2) COAL MINE EMPLOYMENT AFFIDAVIT 3) AFFIDAVIT OF DECEASED MINER'S CONDITION CM-913,, CM-918,, CM-1093

  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 14,000 22,500 0 -8,500 0 0
Annual Time Burden (Hours) 5,084 7,500 0 -2,416 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
02/25/1987


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