Information Collection

1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History

IC 13681 under ICR 200805-1215-006 · OMB 1215-0052.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-911 Miner's Claim for Benefits Under the Black Lung Benefits Act 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form
Form CM-911A Employment History 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form
CM-911 Miner's Claim for Benefits Under the Black Lung Benefits cm-911.pdf www.dol.gov/esa/regs/compliance/owcp/cm-911.pdf	Form
CM-911A Employment History cm-911a.pdf www.dol.gov/esa/regs/compliance/owcp/cm-911a.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.404(a) 20 CFR 725.304(a)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-911			http://www.dol.gov/esa/regs/compliance/owcp/cm-911.pdf	Yes	No	Fillable Printable
Form	CM-911A			http://www.dol.gov/esa/regs/compliance/owcp/cm-911a.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/ESA-6

FR Citation: 67 FR 16869

Number of Respondents: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,500	-1,500	9,000
Annual IC Time Burden (Hours)	5,250	-1,083	6,333
Annual IC Cost Burden (Dollars)	1,449	449	1,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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