Information Collection

1) Miner's Claim for Benefits under the Black Lung Benefits Act; 2) Employment History; 3) Miner Reimbursement Form

IC 13678 under ICR 199903-1215-004 · OMB 1215-0052.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

IC Title:

1) Miner's Claim for Benefits under the Black Lung Benefits Act; 2) Employment History; 3) Miner 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:

table that charts list of 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: 20,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,200	0	20,200
Annual IC Time Burden (Hours)	9,116	0	9,116
Annual IC Cost Burden (Dollars)	4,000	1,000	3,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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