Information Collection

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

IC 13681 under ICR 200506-1215-004 · OMB 1215-0052.

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Information Collection (IC) Details

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IC Title:	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-911A				No	No
Form	CM-911				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,000	-1,700	10,700
Annual IC Time Burden (Hours)	6,333	-1,200	7,533
Annual IC Cost Burden (Dollars)	1,000	0	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.