SUPPORTING STATEMENT
Report of Changes That May Affect Your Black Lung Benefits
CM-929 and CM-929P
OMB No. 1215-0084
A. Justification.
1. The Federal Mine Safety and Health Act of 1977, as amended, 30 USC 936, 30 USC 941 and 20 CFR 725.533(e) authorizes the Division of Coal Mine Workers’ Compensation (DCMWC) to pay compensation to coal miner beneficiaries. Once a miner or survivor is found eligible for benefits, the primary beneficiary is requested to report certain changes that may affect benefits. To ensure that there is a review and update of all claims paid from the Black Lung Disability Trust Fund, and from Social Security cases transferred to the Department of Labor under the Black Lung Consolidation of Administrative Responsibilities Act of 2002, and to help the beneficiary comply with the need to report certain changes, the CM‑929 is sent to all appropriate primary beneficiaries. The CM‑929 is printed by the Division of Coal Mine Workers' Compensation (DCMWC) computer system with information specific to each beneficiary, such as name, address, number of dependents on record, state workers’ compensation information, and amount of current benefits. The beneficiary reviews the information and certifies that the information is current, or provides updated information. The form includes a warning about potential consequences of failure to report changes.
DCMWC uses Information Collection OMB 1215-0173, Forms CM-623 and CM-623S, to monitor a representative payee’s use of funds paid on a beneficiary’s behalf. This is an annual reporting requirement and, while the information collected on OMB 1215-0084 and 1215-0173 is different, the same payees complete both forms and the same DCMWC claims examiner reviews them. Therefore, DCMWC proposes to incorporate the CM-929 into the CM-623 and CM-623S in those cases that appropriately are now sent both forms. This new, composite form is entitled CM-929P, and will allow respondents to verify information to DCMWC once annually instead of twice, as is now required.
2. The CM-929 is used to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Black Lung Disability Trust Fund. The CM-929 is completed by the beneficiary to report factors that may affect his or her benefits, including income, marital status, receipt of state workers' compensation, and dependents’ status. Primary beneficiaries are requested to complete the form upon receipt. The claims examiner carefully reviews the response, verifies information in the claim file, and identifies changes, such as income, marital and dependent status, that may need verification. This information reduces the potential for overpayments and for underpayments. The claims examiner insures that the computer system is updated to reflect appropriate changes.
3. In accordance with the Government Paperwork Elimination Act (GPEA), the forms in this information collection were considered but found to be not practicable for electronic submission. The respondents are retired, disabled coal mine workers and elderly widows. Given the demographics of the customer base, it is unlikely that any significant proportion would have access to the electronic option. It would not be cost effective to make the form electronically interactive for a population that would be unlikely to benefit from such an option. However, even though each form issued by DCMWC is payee-specific and computer‑generated, the forms will be available for downloading and mailing on the DCMWC home page in case claimants misplace the partially completed one that is sent to them. The CM-929 and CM-929p will also be accessible through DOL's on-line forms library at http://www.dol.gov/libraryforms/FormsByNum.asp.
Other Federal agencies have similar reporting requirements, one of which is the Division of Federal Employees' Compensation's Periodic Roll Review. The similar information requested by other agencies cannot be used or modified for the Black Lung Program because our forms, CM-929 and CM-929p, are beneficiary- and Program-specific. Even though the application for benefits requests that specific changes be reported, the CM‑929 and CM-929p are the only existing methods to systematically update the information listed on the application which may affect the amount of benefits and to insure that the beneficiary knows to report those changes.
5. This information collection does not have a significant economic impact on a substantial number of small entities.
6. DCMWC recognizes that an increasing percentage of its beneficiaries require assistance and more careful monitoring because the average age of beneficiaries has grown, and has changed its scheduled mailings of the questionnaires accordingly. The information is requested annually. If the information update were done less frequently, there would be a higher risk of overpayments, underpayments, and erroneous payments to payees due to unreported changes in status.
7. There are no special circumstances for conducting this information collection.
8. During the development of the form, DCMWC utilized the comments of district office and national office staff and the outside consultation of its computer contractor. DCMWC staff has been in contact with form users on an ongoing basis to lend assistance when needed and to monitor the form's usefulness and efficiency. The beneficiaries have found the form easy to understand and complete.
A notice inviting public comment on this information collection was published in the Federal Register on December 12, 2007. No comments received.
9. Respondents do not receive gifts or payments to furnish the requested information. However, the respondents are entitled to and do receive monthly benefits.
10. The Privacy Act System (ESA‑6 and ESA-30) provides confidentially of information collection involving a claimant's records. Additionally, the Form CM-929 displays a Privacy Act disclosure statement.
11. There are no questions of a sensitive nature in these forms.
12. There are approximately 70,000 computer‑generated CM‑929 forms sent to all beneficiaries (one each) on a yearly basis to certify and/or correct information reflected in DCMWC's files. We estimate that 87% of 70,000 beneficiaries, or 60,900, will be sent Form CM-929, and the remaining 13%, or 9,100, will be sent the Form CM-929P. DCMWC experience has been that 90% of all completed Forms CM-929 are essentially certifications. The remaining 10% of completed forms reflect correction of data. DCMWC estimates that the time required of respondents to read the CM‑929 and certify that all benefit information is correct and accurate is five minutes. The time required to read the form and report one or more corrections to the benefit information is no more than eight minutes. Therefore, the estimated total burden to the 60,900 beneficiaries in completing this form is 5,380 burden hours, based on the following:
90% of 60,900 = 54,810 x 5 minutes = 4,568 hours
10% of 60,900 = 6,090 x 8 minutes = 812 hours
Benefits due a DOL black lung beneficiary may be paid to a representative payee on behalf of the beneficiary when the beneficiary is unable to manage his/her benefits due to incapability, incompetence or minority. The CM-929P form is used to collect expenditure data regarding the disbursement of the beneficiary's benefits by the payee to assure that the beneficiary's needs are being met. This form, CM-929P replaces forms CM-623 and CM-623S in most cases because they will no longer be sent separately. The burden hours for the existing independent OMB 1215-0173 will be reduced by more than the increased burden of the present clearance because some of the information on both forms is similar, and because only one form is involved instead of two, thereby reducing the chance that one of the forms will be lost or misplaced. Note: The information collection 1215-0173 will be submitted in June 2008 with the reduction in burden.
In turn, approximately 20% of the respondents to the Representative Payee Report use the short form, CM-623S, which does not require detailed financial information from payees who live in the same household as the beneficiaries. This form is included in the combined CM-929P with a clear instruction for the representative payee to skip over questions that do not apply to his/her situation.
We estimate the burden on respondents who answer the full CM-929P, or about 7,280 payees, to be reduced by about 10 minutes, from 90 to 80 minutes per form, and we have estimated the burden on respondents who answer the short version to be reduced about 4 minutes, from 10 to 6 minutes. Therefore, we have calculated the total burden to be 9,889 hours as follows:
80% of 9,100 = 7,280 x 80 minutes = 9,707 hours
20% of 9,100 = 1,820 x 6 minutes = 182 hours
Subtotal Burden Hours for CM-929 = 5,380 hours
Subtotal Burden Hours for CM-929P = 9,889 hours
Total Burden Hours = 15,269 hours
There is no monetary cost to the respondent to provide this information; rather, the submission of this information is an intrinsic part of the benefit process. However, to comply with PRA 1995, we used the Federal minimum wage as a representative wage rate to calculate the cost of the burden hours.
15,269 x $5.85 = $89,324.
13. There are no technological or system costs associated with the collection of this information. This form is a postage paid self mailer.
14. The estimated total cost to the Federal Government for development, printing, mailing and processing the CM-929 and CM-929P is approximately $502,106.00. The cost is computed as follows:
a. Estimated printing cost for 80,500 forms $16,060.00
This includes printing the initial mailing of 70,000 and follow-up printing to beneficiaries who do not respond to the first mailing of 10,500.
70,000 + 10,500 = 80,500.
b. Estimated cost for mailing and returning the form $37,030.00 + $39,200.00 = $76,230.00
This includes follow-up mailings to beneficiaries who do not respond to the first mailing. DCMWC mails approximately 39,100 forms to the beneficiaries
80,500 x 46¢ = $37,030.00 for out going mail.
41¢ + 5¢ + 10¢ = 56¢ includes cost of return postage, envelope and .10¢ postal surcharge)
70,000 x 56¢ = $39,020.00 for responses.
c. Estimated processing cost $409,816.00
A GS‑12/5 spends an average of 6 minutes evaluating each CM-929 form and each partially-completed CM-929P, and 30 minutes evaluating each fully-completed CM-929P. A GS‑6/4 spends an average of 3 minutes on clerical duties associated with each form. The FY 2008 Salary Table for the RUS was used to determine Federal cost.
CM-929 60,900 x 6 min= 6,090 hours x $35.47 = $213,139.00
CM-929P(p) 1,820 x 6 min= 182 hours x $35.47 = $ 6,456.00
CM-929P(f) 7,280 x30 min= 3,640 hours x $35.47 = $129,111.00
Both 70,000 x 3 min= 3,500 hours x $17.46 = $ 61,110.00
Total $409,816.00
15. The total burden hours have increased by 10,764 hours, from 4,505 to 15,269. The total number of responses increased in the previous clearance because the Department of Labor was given complete responsibility for all Part B (Social Security) and Part C (Trust Fund) beneficiaries by the Black Lung Consolidation of Administrative Responsibilities Act (BLCARA.) The Department of Labor did not determine that the reporting requirements of the CM-929 applied to Part B beneficiaries until the BLCARA became law.
In this clearance, the burden hours are increasing again because of a program change in requiring reporting of benefits received annually instead of biennially in order to ensure more accurate payment of benefits. The program requirement that representative payees report annually is unchanged. However, the increase in burden hours reflected in this clearance will be offset by a decrease in burden hours of approximately 4,148 hours in OMB 1215-0173 because the current forms CM-623 and CM-623S will only be used in cases where the representative payee needs to account for benefits received after the death of the beneficiary. Thus, the net change in burden for the two OMB clearances is an increase of 6,983 hours.
Existing Burden.
90% of 51,000 = 45,900 x 5 minutes = 3,825 hours
10% of 51,000 = 5,100 x 8 minutes = 680 hours
Total= 4,505 hours
Total proposed Burden = 15,269 hours
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.
18. There are no exceptions to the certification statement.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | Charles Lloyd |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2008-04-10 |
| File Created | 2008-04-10 |