Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-911A Employment History	Form	Modified	Repair queued
Form CM-911 Miner's Claim for Benefits Under the Black Lung Benefits Act	Form	Modified	Available
1215-0052 Supporting Statement July 23 2008.doc	Supporting Statement A	Uploaded 2008-07-23	Available
20CFR725.304 - Forms and initial processing..pdf	Supplementary Document	Uploaded 2008-05-19	Available
DOL Privacy Act systems ESA-30.pdf	Supplementary Document	Uploaded 2008-05-04	Available
DOL Privacy Act systems ESA-6.pdf	Supplementary Document	Uploaded 2008-05-04	Available
20CFR725.404 - Development of evidence--general..pdf	Supplementary Document	Uploaded 2008-05-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Employment History
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Miner's Claim for Benefits Under the Black Lung Benefits Act

ICR Details

OMB Control No: 1215-0052	ICR Reference No: 200805-1215-006
Status: Historical Active	Previous ICR Reference No: 200506-1215-004
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/05/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/30/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2011	36 Months From Approved	09/30/2008
Responses	7,500	0	9,000
Time Burden (Hours)	5,250	0	6,333
Cost Burden (Dollars)	1,449	0	1,000

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Abstract: CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and this form is completed by all applicants, both miners and survivors.

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Authorizing Statute(s): US Code: 30 USC 901
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 23274	04/29/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 44281	07/30/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	CM-911, CM-911A	Miner's Claim for Benefits Under the Black Lung Benefits Act ,   Employment History

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ICR Summary of Burden

table that charts list of burden

	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	7,500	9,000	0	0	-1,500	0
Annual Time Burden (Hours)	5,250	6,333	0	0	-1,083	0
Annual Cost Burden (Dollars)	1,449	1,000	0	0	449	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is an adjustment reduction of respondents from 9,000 to 7,500 because there are fewer black lung applicants. The burden hour is an adjustment reduction from 6,333 to 5,250 which is a difference of -1,083 burden hours due to fewer applicants. There has been an increase to the operation and maintenance cost from $1,000 to $1,449 due to increase in postage.

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Annual Cost to Federal Government: $119,260

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/30/2008

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