SUPPORTING STATEMENT
Authorization for Release of Medical Information (CM-936)
OMB NO. 1215-0057
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.
When a person files a claim for black lung benefits, the individual may submit medical information to the Division of Coal Mine Workers' Compensation (DCMWC) to help develop the claim. The CM-936 is a form that gives the claimant's consent for the release of medical information covered by the Privacy Act of 1974, and contains information required by medical institutions and private physicians to enable them to release pertinent medical information. The Black Lung Benefits Act, as amended, 30 USC 901 et. seq. and 20 CFR 725.405 require that all relevant medical evidence be considered before a decision can be made regarding a claimant's eligibility for benefits.
Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
The CM-936 is used by black lung claimants who wish to submit medical evidence to support their claim. The form provides the claimant's consent for medical institutions and private physicians to release medical information to DCMWC. The form may be completed by the claimant and the claims examiner (CE). If the CE completes the form from information already in the claim file, the claimant must verify and sign the request.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
This form is available for downloading from the DCMWC web site by respondents. It may also be completed and submitted online with an electronic signature. The form may be accessed at http://www.dol.gov/esa/owcp/regs/compliance/cm-936.pdf.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
The Federal Black Lung Program has no other medical release form. Other programs have medical release forms; however, they are program-specific for covered occupational illnesses and do not specifically request medical evidence related to the adjudication of black lung claims.
5. If the collection information impacts small businesses or other small entities (Item 5 of 014B Form 83-1), describe any methods used to minimize burden.
This information does not have a significant impact on a substantial number of small entities.
6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
If this form were not used, the adjudication of the black lung claim would be incomplete, because pertinent medical data would not be available for consideration.
7. Explain any special circumstances
There are no special circumstances for collection of this information.
If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
The Social Security Administration (SSA) was contacted during the development of the CM-936, because the form is based upon a similar SSA form. Both SSA and Department of Labor (DOL) obtain this information from claimants, because it is necessary to obtain all the evidence available concerning the claimant’s medical condition. The information is readily available and is only collected once. There have been no complaints concerning the CM-936 or its clarity of instructions, record keeping, disclosure, record format, cost or hour burden or data elements to be recorded, disclosed or reported.
The DOL published a notice in the Federal Register on April 2, 2009 inviting comments about this information. 74 Fed. Reg. 15005. The agency received no comments in response to this notice.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
Respondents do not receive gifts or payments for furnishing the requested information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
The Privacy Act Issuance (ESA-6 and ESA-30) provides for confidentiality of information collected for a claimant's record.
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
There are no questions of a sensitive nature asked on the form.
12. Provide estimates of the hour burden of the collection of information.
The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information. The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.
There are approximately 900 respondents annually. One form is sent to each respondent, who spends approximately 5 minutes to complete and mail the form. Thus, there is an annual burden of 75 hours.
To estimate the annual cost of the burden hours to the CM-936 respondents, the Federal minimum wage, which is $6.55 per hour, has been applied. Thus, the total annual cost to CM-936 respondents is $491.25 ($6.55 X 75 burden hours).
Annual Costs to Respondents (capital/start-up & operation and maintenance).
There is no cost burden to respondents or record keepers resulting from the collection of this information.
14. Provide estimates of annualized cost to the Federal government.
The estimated total cost to the Federal Government for the 900 forms is approximately $3,268.75. The cost is computed as follows: (A +B + C)
a. Estimated printing and distribution cost is $40.00.
b. Estimated mailing cost is $810.00 (includes cost of envelope and stamp, and return, stamped envelope, at a cost of 90 cents per item.)
c. Estimated processing cost is computed at one claims examiner (GS 12/5) spending approximately 5 minutes reviewing the form. (The OPM FY 09 GS Salary Table was used for the hourly wages.)
75 hours x $32.25 per hour = $2,418.75
Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.
The estimated burden hour is an adjustment from 100 hours to 75 hours, which is a decrease of -25 hours. The reduction is due to a decline in the number of persons applying for black lung benefits, and because a change in program regulations in 2001 has reduced the number of claimants for which DCMWC is required to request medical records.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
There are no plans for publishing statistical data based on this information collection.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
This request does not seek a waiver from the requirement to display the expiration date.
18. Explain each exception to the certification statement identified in Item "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.
There are no exceptions to the certification statement.
| File Type | application/msword |
| File Title | MEMORANDUM FOR: |
| Author | Department of Labor |
| Last Modified By | US Department of Labor |
| File Modified | 2009-07-13 |
| File Created | 2009-07-07 |