Report of Changes That May Affect Your Black Lung Benefits

Forms and Documents

Document Name	Status
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits Form	Modified
1215-0084 QandA June 2008.doc Supplementary Document	2008-06-11
Supporting Statement 1215-0084 (CM-929 and 929P) 4-10-2008 HB.doc Supporting Statement A	2008-04-10
CM-929 4-2-2008.doc Supplementary Document	2008-04-09
CM-929P 4-2-2008.doc Supplementary Document	2008-04-09
OMB 83-1 1215-0084 November 2007.pdf Supplementary Document	2008-04-02
30 USC Sec_ 936 (1993).htm Supplementary Document	2008-03-12
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2008-03-12

IC Document Collections

IC ID	Document Title	Status
13756	Report of Changes That May Affect Your Black Lung Benefits Form	Modified

ICR Details

OMB Control No: 1240-0028	ICR Reference No: 201003-1240-028
Status: Historical Active	Previous ICR Reference No: 200504-1215-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Report of Changes That May Affect Your Black Lung Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/12/2010
	Date Received in OIRA: 03/12/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2011	36 Months From Approved
Responses	70,000	0	51,000
Time Burden (Hours)	15,269	0	4,505
Cost Burden (Dollars)	0	0	0

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Abstract: To help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Disability Trust Fund. To verify and update on a regular basis factors that affect a beneficiary's entitlement to benefits, including income, marital status, receipt of State Worker's Compensation, and dependent status.

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Authorizing Statute(s): US Code: 30 USC 936 Name of Law: Federal Mine Safety and Health Act
  

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:
	72 FR 70616	12/12/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 22432	04/25/2008
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Report of Changes That May Affect Your Black Lung Benefits	CM-929, CM-929P	Report of Changes That May Affect Your Black Lung Benefits ,   Report of Changes That May Affect Your Black Lung Benefits

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ICR Summary 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	70,000	51,000	0	19,000	0	0
Annual Time Burden (Hours)	15,269	4,505	0	10,764	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The total burden hours have increased by 10,764 hours, from 4,505 to 15,269. The burden hours have increased because of a program change in requiring reporting of benefits received annually instead of biennially in order to ensure more accurate payment of benefits.

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Annual Cost to Federal Government: $502,106

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: 04/25/2008

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