SUPPORTING STATEMENT
Certification by School Official (CM-981)
OMB No. 1215-0061
1. In order to qualify as an eligible dependent for black lung benefits, a child aged 18 to 23 must be a full-time student as described in the Black Lung Benefits Act, 30 USC 901 et. seq. and attending regulations 20 CFR 725.209. The form CM-981 is used to verify full-time student status.
2. Once a child aged 18 is identified, the claims examiner (CE) determines if the child is a student and obtains the name and address of the school. The CE completes the upper half of the CM-981 and mails it to the school. The school official completes the remainder, signs it, and returns it to DCMWC. The CE reviews it to insure that the dependent, from the ages of eighteen to twenty-three, is a full-time student. If so, benefits for the dependent continue to be paid. If the dependent is not a full-time student or if the form is not returned, benefits on behalf of a dependent student will be suspended or terminated.
The CM-981 is partially completed by the appropriate district office so that the school official or registrar’s office will know for which student and time period the information is being requested. At the time of request, the appropriate district office address and the telephone number are placed on the form. The partially completed form is sent to the registrar’s office together with a return envelope. The information requested is readily available from the registrar. In accordance with the Government Paperwork Elimination Act (GPEA), this form has also been made available on-line, and may be submitted in one of three different methods if the registrar’s office chooses. A) The form may be downloaded, printed, completed by hand, and mailed. B) It may be downloaded, completed on-screen, printed, signed by hand, and mailed. C) It may be downloaded, completed on-screen, and submitted on-line with a digital signature to a secure server within the Department of Labor. The form is available on the DCMWC public website at http://www.dol.gov/esa/regs/compliance/owcp/cm-981.pdf. The URL for the form is printed on a brief cover letter that accompanies the CM-981 for use by the Registrar’s office in the event that the original form is lost or destroyed before it is returned.
There is no similar approved information collection
form used by the Program. The Federal Employees' Compensation Program and the Social Security Administration collect similar information but from a different beneficiary population.
5. This information collection does not have a significant economic impact on a substantial number of small entities.
6. If full-time student status for dependents aged 18 to 23 were verified less than yearly, there would be no dependable way to know if eligibility continues. This could create a hardship to the beneficiary because the monthly benefit check could be less than should be received, or the beneficiary could be paid too much if we incorrectly assumed full-time status. In order to determine continued eligibility, this verification must be done yearly.
7. There are no special circumstances for this information collection.
8. No outside consultants were contacted concerning the use of the CM-981. The form has been in use since 1978, and there has been ample time to voice any complaints regarding its use.
A Federal Register Notice inviting comments was published on November 14, 2006. No comments were received.
9. Respondents do not receive gifts or payments to furnish the requested information.
10. The attached Privacy Act System Notice, ESA-6, provides confidentiality of information involving a claimant's record.
11. There are no questions of a sensitive nature on this form.
12. It is estimated that it takes the school's registrar about 10 minutes to retrieve the needed information, complete, mail the CM-981, and replace the records. Based on an average of the number of forms received annually since the last clearance, it is estimated that approximately 400 forms are completed in a year for about 67 burden hours.
10 X 400 = 67
60
The estimated annualized cost to the respondents is $17.18 per hour (Employment and Earnings, Table B2 published September 2006 by the Bureau of Labor Statistics: average of most recent five months at ftp://ftp.bls.gov/pub/suppl/empsit.ceseeb18.txt) for the collection of this information for an approximate total of $1151.00.
$17.18 x 67 hours = $1151.00
13. There are no operation and maintenance costs to respondents.
14. The estimated total cost to the Federal Government for these 400 forms is approximately $2316.33. The cost is figured as follows:
a. Estimated printing cost: $35.00.
b. Estimated mailing cost: $336.00 ($.39 postage plus $.03 per envelope = $0.42 plus an additional $.42 = $.84 for stamps and envelopes for mailings and returns) 400 forms x $.84 = $336.00.
c. The estimated processing cost: $1,945.33 calculated at one CE (GS-12/4) spending about 10 minutes completing and evaluating the form. (The Salary Table 2006-GS was used for the hourly wages.)
$29.18 X 400 = $1,945.33
6
15. There is an adjustment to the number of students requiring verification. Because of the aging of the black lung population, there are fewer students age 18 and over who are attending school full-time. Since the number of forms represent approximately twice the number of students age 18 and over, with student status verified once each term, there is a corresponding reduction of forms and burden hours to the public. The number of respondents has decreased from 500 to 400. The number of burden hours has decreased from 84 hours to 67 hours, which resulted in an adjustment of -17 burden hours.
Form No. Previous New Difference Type of
Burden Burden Change
CM-981 84 67 -17 ADJ.
16. There are no plans to publish this collection of information.
17. This ICR does not seek a waiver from the requirement to display the expiration date. The expiration date will be displayed on the Form CM-981.
18. There are no exceptions to the certification statement.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | US Department of Labor |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2007-02-09 |
| File Created | 2007-02-09 |