Supporting Statement
CM‑905, Request for State or Federal Workers' Compensation Information
OMB No. 1215-0060
A. Justification.
1. The Federal Mine Safety and Health Act of 1977, as amended (30 U.S.C. 901 et. seq.) and 20 CFR 725.535 require that DOL Black Lung benefit payments to a beneficiary for any month be reduced by any other payments of state or federal benefits for workers' compensation due to pneumoconiosis. To ensure compliance with this mandate, DCMWC must collect information regarding the status of any state or Federal workers' compensation claim, including dates of payments, weekly or lump sum amounts paid, and other fees or expenses paid out for this award, such as attorney fees and related expenses associated with pneumoconiosis. A social security number is mandated for the information collection per Public Law 106-113.
2. This form is submitted to Federal or state agencies for completion when it is indicated that the beneficiary has filed a claim for workers' compensation benefits due to pneumoconiosis, or is receiving benefits that may need to be offset. State or Federal workers' compensation programs are directed to notify DCMWC of any rate changes or cessation of compensation benefits. Usually only one CM‑905 is sent; however, a second CM‑905 may be sent if the claims examiner suspects recent activity regarding a claimant's state workers' compensation claim, but has no recent CM‑905 information in file. Information is used by DCMWC claims examiners in determining the amounts of black lung benefits paid to beneficiaries. Benefit amounts are reduced, dollar for dollar, for other black lung related workers' compensation awards the beneficiary may be receiving from state or Federal programs.
3. In the OWCP Black Lung GPEA Forms Final Transformation Status report, OWCP determined that the CM-905 form should not be made available on the Internet because it is initiated by the DCMWC claims examiner 100% of the time. It is not usable by the state workers’ compensation official unless it contains identifying information supplied by DCMWC. It requires the signatures of both the claims examiner and the state official. Because workers’ compensation information is covered by the Privacy Act or similar state privacy statutes, the DCMWC examiner’s personal or digital signature is usually required for the state to release information, and an on-line or PDF form on the DCMWC website would not permit submission to the state workers’ compensation agency.
4. There are no similarly approved forms used within the program. No other ESA program or Federal agency has similar requirements. The collection of this information is specific for workers' compensation benefits due to pneumoconiosis.
5. No small businesses are affected by the collection of this data.
6. This information is collected only at the time a beneficiary indicates that he has filed an occupational disease claim for pneumoconiosis with a state government or another Federal workers’ compensation program. DCMWC must verify that the claimant filed for Federal or state benefits and any amount of compensation the claimant may receive due to black lung disease. Without this information, an overpayment may occur to the claimant because state benefits offset federal black lung benefits.
7. There are no special circumstances for this information collection.
8. Consultation with state or Federal workers' compensation programs occurs whenever the form is sent out and the response is unclear either to that program or to DOL. No problems have resulted from use of this form.
A Federal Register Notice was published on April 25, 2007 inviting public comment. No comments were received.
9. Respondents do not receive gifts or payments to furnish the requested information.
10. The attached Privacy Act System notices (ESA‑6 & ESA‑30) provide confidentiality of information collection involving Black Lung claimant files and computerized data.
11. No questions of a sensitive nature appear on this form.
12. The public burden estimate of this information collection is approximately 350 hours. The estimated burden is based on the submission of approximately 1400 forms. This represents about 1400 black lung claimants who may have filed occupational disease claims with a state or Federal government. Each response averages 15 minutes per form for a total of 350 hours to collect the data for 1,400 forms.
1400 x 15 minutes = 350 hours
The estimated annualized cost to respondents to provide this information is rounded to $6,934.00 (350 hours x $19.81 per hour = $6,933.50). The hourly wage of $19.81 is taken from the Current Employment Statistics Table B3, published by the Bureau of Labor Statistics in January 2007, under the heading of Professional and Business Services (highlighted on attachment.) The table may be found at: http://www.bls.gov/news.release/empsit.t16.htm
13. (a) Total capital and start-up costs: None.
(b) Total operation, maintenance, and purchases of services component:
Estimated mailing costs: $616.00
[(41¢ stamp + 3¢ envelope) 44¢ x 1400 = $616.00]
14. The estimated cost to the Federal Government for these 1,400 forms is approximately $12,466.50. The cost is figured as follows:
a. Estimated printing cost: $150.00
b. Estimated mailing cost: $616.00
(41¢ plus 3¢ per envelope for a total of 44¢ per form)
c. The estimated processing cost: $11,700.50
[one CE GS‑12/4 spends about 15 minutes evaluating each form or 350 hours ($33.43 x 350 = $11,700.50)]
15. 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.
BURDEN HOURS RESPONSES O&M COST
Current inventory 400 1,600 $ 624.00
Requested 350 1,400 $ 616.00
Differences -50 -200 $ -8.00
16. There are no plans to publish this information.
17. This ICR does not seek a waiver from the requirement to display the expiration date.
18. There are no exceptions to the certification statement.
| File Type | application/msword |
| Author | lisa h flowers |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2007-06-11 |
| File Created | 2007-06-11 |