SUPPORTING STATEMENT
Survivor's Form for Benefits (CM-912)
OMB No. 1215-0069
A. Justification.
1. This collection of information is required to administer the benefit payment provisions of the Black Lung Benefits Act for survivors of deceased miners. Completion of this form constitutes the application for benefits by survivors and assists in determining the survivor's entitlement to benefits. This form is authorized by the Black Lung Benefits Act (30 USC 901, et seq.) and by 20 CFR 410.221 and 20 CFR 725.304.
2. Survivor applications are used by Division of Coal Mine Workers' Compensation (DCMWC) claims examiners to determine a survivor's eligibility for benefits. The claims examiners review the information submitted with the survivor's application along with any pertinent evidence already in file and, as necessary, informs the claimant of any additional information needed to meet the eligibility requirements to adjudicate the claim. The eligibility requirements are given in 20 CFR 725.212-225.
3. The form is available for downloading at http://www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf. It can be filled out on-screen, printed, and mailed, or it may be printed, completed by hand, and mailed. However, it has not been made available for electronic submission. The form requires the signature of the claimant, which could be affixed electronically, but it also contains a space for the signature of a witness if the claimant is unable to sign his or her name. Two independently-obtained digital signatures by different people would be required to submit such a form on-line and, in order to keep claim information confidential, the Department of Labor’s web site does not permit forwarding or submission of on-line forms to any place other than the Department’s designated electronic mailbox. This would prevent the claimant from forwarding the form to the witness after both had received their digital signature verification keys.
4. There is no similar approved form used by DCMWC. Since the information collected is specific to Federal Black Lung beneficiary survivors, no other agency gathers this information.
5. Collection of this information does not involve small businesses or other small entities.
6 This is a one-time collection from applicants; if the collection were less frequent, survivors eligible for benefits under the Black Lung Benefits Act would not be able to exercise their right to apply.
7. There are no special circumstances for conducting this information collection.
8. Consultations with respondents take place at anytime a question or problem is raised.
A Federal Register Notice inviting public comment was published on March 6, 2007. No comments were received.
9. Respondents do not receive any gifts or payments to furnish the requested information.
10. Privacy Act System Notices (ESA-6 and ESA-30) provide confidentiality of information collected involving a claimant's claim file and automated record.
11. There are no questions of a sensitive nature on this form.
12. The burden estimate for the CM-912 is based upon the
approximately 2,000 forms received yearly by DCMWC district
offices. A survivor needs to fill out an application only
once. It takes approximately 8 minutes per response, for a
total annual burden of 267 hours.
(2000 forms x 8 min= 16,000 min/60 = 266.67 hours)
The estimated total cost to respondents for the burden hours is approximately $1,062.00. The cost is computed by using the hourly Black Lung beneficiary benefit rate of $3.98. ($584 monthly x 12 = $7,008 a year/220 OPM annual workdays = $31.85/8 work hours a day = $3.98 hourly. $3.98 x 267 work hours = $1062.66)
13. Operation and maintenance costs consist of mailing costs for the form. Approximately 400 of the forms are completed at Black Lung or Social Security offices and thus incur no mailing costs. About 1,600 of the completed responses are mailed to the Black Lung offices at a cost of $.44 ($.41 postage and .03 for the envelope), for a total of $704.00. ($.44 x 1600 = $704)
14. The estimated total cost to the Federal government for this information collection is approximately $19,862.00. The cost is computed as follows:
a. Estimated printing cost: $571.00
b. Estimated mailing cost: $704.00
(stamps and envelopes @ $.44 for 1,600 forms sent to the claimant for completion, this excludes the approximate 400 forms completed by a Black Lung or Social Security office)
c. Estimated processing cost: $14,840.00
(Claims Examiner, GS-12/4, spends about 15 minutes evaluating each form: $29.68 x 2,000/4 = $14,840.00) (The Salary Table 2007 – GS is used for this submission.)
d. Estimated SSA contract costs: $3,747.00
(SSA is under contract with DCMWC for claim taking services at SSA district offices throughout the country. The price per claim intake is $37.47. Of the 400 responses taken at DCMWC or SSA offices, it is estimated that approximately 100 will be taken by SSA. (100 x $37.47 = $3,747.00)
15. There is a decrease in the approximate number of respondents from 2,800 to 2,000, due to the mortality rate of an aging claimant population. Accordingly, there is an adjustment of burden hours from 373 to 267 is a decrease of -106 hours and cost burden from $1,000 to $704.
BURDEN HOURS RESPONSES
Current inventory 373 2,800
Requested 267 2,000
Difference -106 -800
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 |
| Author | US Department of Labor |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2007-05-30 |
| File Created | 2007-05-30 |