Request for State or Federal Workers' Compensation Information

ICR 200704-1215-001

OMB: 1215-0060

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2007-07-11
Supplementary Document
2007-06-11
Supplementary Document
2007-06-11
Supplementary Document
2007-06-11
Supporting Statement A
2007-06-11
IC Document Collections
ICR Details
1215-0060 200704-1215-001
Historical Active 200407-1215-002
DOL/ESA
Request for State or Federal Workers' Compensation Information
Extension without change of a currently approved collection   No
Regular
Approved without change 09/21/2007
Retrieve Notice of Action (NOA) 07/19/2007
  Inventory as of this Action Requested Previously Approved
09/30/2010 36 Months From Approved 09/30/2007
1,400 0 1,600
350 0 400
616 0 1,000

DCMWC beneficiaries have their monthly benefits reduced dollar for dollar for other benefits that they receive attributable to their black lung disability from State or Federal workers' benefits. The CM-905 request the amount of those workers' compensation benefits.

US Code: 30 USC 901 Name of Law: The Federal Mine Safety and Health Act of 1977, as amended
  
None

Not associated with rulemaking

  72 FR 20565 04/25/2007
72 FR 39463 07/18/2007
No

1
IC Title Form No. Form Name
Request for State or Federal Workers' Compensation Information CM-905 Request for State or Federal Workers' Compensation Information

  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 1,400 1,600 0 0 -200 0
Annual Time Burden (Hours) 350 400 0 0 -50 0
Annual Cost Burden (Dollars) 616 1,000 0 0 -384 0
No
No
The total number of burden hours has decreased by 50 hours and the total response has been reduced due to fewer black lung claimants who filed for occupational disease benefits with a state or Federal government. This is an adjustment of -50 burden hours and -200 responses. There is an operation and maintenance cost decrease due to fewer black lung claimants from $624 to $616 which is an adjustment of -8. In the previous submission because operation and maintenance costs had to be shown in the thousands there is a discrepancy in what is shown in the supporting statement and what in shown in ROCIS.

$12,467
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Michael McClaran 202-693-0978 [email protected]

  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.
07/19/2007


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