Miner's Claim for Benefits under the Black Lung Benefits Act, Employment History, Miner Reimbursement Form

ICR 199602-1215-003

OMB: 1215-0052

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0052 199602-1215-003
Historical Active 199502-1215-001
DOL/ESA
Miner's Claim for Benefits under the Black Lung Benefits Act, Employment History, Miner Reimbursement Form
Extension without change of a currently approved collection   No
Regular
Approved without change 04/29/1996
Retrieve Notice of Action (NOA) 02/29/1996
Approved as amended by DOL memorandum of 4/23/96, 4/24/96 and 4/25/96. It is noted however that ESA shall recognize in future PRA submissions that there is a burden cost placed on the beneficiaries when filling out these forms despite the respondents current employment status.
  Inventory as of this Action Requested Previously Approved
05/31/1999 05/31/1999 04/30/1996
20,200 0 52,700
9,116 0 14,533
3,000 0 0

CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. CM-911a lists the coal miner's work history and is completed by all applicants, miners, and survivors. CM-915 is used by the miner or survivor for requesting reimbursement of medical expenses incurred and paid by a miner beneficiary.

None
None


No

1
IC Title Form No. Form Name
Miner's Claim for Benefits under the Black Lung Benefits Act, Employment History, Miner Reimbursement Form CM-911, CM-911A, CM-915

  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 20,200 52,700 0 0 -32,500 0
Annual Time Burden (Hours) 9,116 14,533 0 0 -5,417 0
Annual Cost Burden (Dollars) 3,000 0 0 3,000 0 0
No
No

$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.
02/29/1996


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