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

MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG ACT, EMPLOYMENT HISTORY, AND MINER MEDICAL REIMBURSEMENT FORM

OMB: 1215-0052

IC ID: 121954

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MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG ACT, EMPLOYMENT HISTORY, AND MINER MEDICAL REIMBURSEMENT FORM
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CM-911, No No
Form CM-911A, No No
Form & CM-915 No No


    

54,500 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 54,500 0 -3,000 0 0 57,500
Annual IC Time Burden (Hours) 17,166 0 -3,668 0 0 20,834
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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