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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0052 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

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: Required to Obtain or Retain Benefits

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: 54,500	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	54,500	-3,000	57,500
Annual IC Time Burden (Hours)	17,166	-3,668	20,834
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.