Information Collection

Black Lung Provider Enrollment Form

IC 38461 under ICR 200107-1215-005 · OMB 1215-0137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0137 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Black Lung Provider Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OWCP-1168				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,000	4,000	4,000
Annual IC Time Burden (Hours)	767	467	300
Annual IC Cost Burden (Dollars)	3,000	2,000	1,000

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.