OMB 83-1

PAPERWORK REDUCTION ACT SUBMISSION
Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW
Washington, DC 20503.
1. Agency/Subagency originating request

2. OMB control number
a. 1215

USDOL/ESA/DCMWC
3. Type of information collection (check one)
a.

-

b.

4. Type of review requested (check one)

New collection

a.

Revision of a currently approved collection

b.

Emergency - Approval requested by:

c.

Extension of a currently approved collection

c.

Delegated

d.

Reinstatement, without change, of a previously approved
collection for which approval has expired
Reinstatement, with change, of a previously approved
collection for which approval has expired
Existing collection in use without an OMB control number

b.

✘

e.
f.

None

0084

Regular

✘

5. Small entities
Will this information collection have a significant economic impact on
✘
a substantial number of small entities?
Yes
No
6. Requested expiration date
a.

For b-f, note item A2 of Supporting Statement instructions.

✘

Three years from approval date b.

Other Specify:

7. Title

Report of Changes That May Affect Your Black Lung Benefits
8. Agency form number(s) (if applicable)

CM-929, CM-929P
9. Keywords

Coal Mine Benefits, Compensation Benefits, Representative Payee
10. Abstract

To help determine continuing eligibility of primary benficiaries 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. To allow representative payees to report changes and verify benefits received,
conserved, and spent on a beneficiary on a single form.
11. Affected public (Mark primary with "P" and all others that apply with "X")
a. P Individuals or households
d.
Farms
b.
Business or other for-profit e.
Federal Government
c. X Not-for-profit institutions

f.

State, Local or Tribal Government

13. Annual reporting and recordkeeping hour burden
70,000

a. Number of respondents
b. Total annual responses
1. Percentage of these
responses collected electronically
c. Total annual hours requested

70,000
0 %

15,269

4,505

d. Current OMB inventory
e. Difference
f. Explanation of difference

10,764

10,764

1. Program change
2. Adjustment

15. Purpose of information collection (Mark primary with "P" and all others that
apply with "X")

a.
Application for benefits
b. P Program evaluation

e. X Program planning or management
f.
Research

c.
d.

g. X Regulatory or compliance

General purpose statistics
Audit

12. Obligation to respond (Mark primary with "P" and all others that apply with "X")
a.
b.
c.

Voluntary
P Required to obtain or retain benefits

Mandatory

14. Annual reporting and recordkeeping cost burden (in thousands of dollars)
0
a. Total annualized capital/startup costs
b. Total annual costs (O&M)
c. Total annualized cost requested

0
0

d. Current OMB inventory
e. Difference
f. Explanation of difference

0

1. Program change
2. Adjustment

16. Frequency of recordkeeping or reporting (check all that apply)
a.
b.
Third party disclosure
Recordkeeping
c. ✘ Reporting
1.
2.
3.
On occasion
Weekly
Monthly
4.
5.
Quarterly
Semi-annually 6. ✘ Annually
7.

17. Statistical methods
Does this information collection employ statistical methods?
Yes

0

Biannually

8.

Other (describe)

18. Agency contact (person who can best answer questions regarding the content
of this submission)
✘

No

Name: Michael McClaran
Phone: (202) 693-0978

OMB 83-I

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19. Certification for Paperwork Reduction Act Submissions
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with
5 CFR 1320.9.
NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8 (b) (3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in
the instructions.
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 terminology 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):
(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 of 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 (see note in Item 19 of the instructions);
(i) It uses effective and efficient statistical survey methodology; and
(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason
in Item 18 of the Supporting Statement.

Signature of Authorized Agency Official

Date

Signature of Senior Official or designee

Date

OMB 83-I

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Instructions For Completing OMB Form 83-I
Please answer all questions and have the Senior
Official or designee sign the form. These instructions should be used in conjunction with 5 CFR
1320, which provides information on coverage, definitions, and other matters of procedure and interpretation under the Paperwork Reduction Act of 1995.
1.

5.

Indicate whether this information collection
will have a significant impact on a substantial
number of small entities. A small entity may
be (1) a small business which is deemed to be
one that is independently owned and operated
and that is not dominant in its field of operation; (2) a small organization that is any notfor-profit enterprise that is independently
owned and operated and is not dominant in its
field; or (3) a small government jurisdiction
which is a government of a city, county, town,
township, school district, or special district
with a population of less than 50,000.

Agency/Subagency originating request
Provide the name of the agency or subagency
originating the request. For most cabinet-level
agencies, a subagency designation is also necessary. For non-cabinet agencies, the subagency designation is generally unnecessary.

2.

OMB control number

6.

a. If the information collection in this request
has previously received or now has an OMB
control or comment number, enter the number.
b. Check "None" if the information collection
in this request has not previously received an
OMB control number. Enter the four digit
agency code for your agency.
3.

Type of information collection (check one)
a. Check "New collection" when the collection has not previously been used or sponsored by the agency.
b. Check "Revision" when the collection is
currently approved by OMB, and the agency
request includes a material change to the collection instrument, instructions, its frequency
of collection, or the use to which the information is to be put.
c. Check "Extension" when the collection is
currently approved by OMB, and the agency
wishes only to extend the approval past the
current expiration date without making any
material change in the collection instrument,
instructions, frequency of collection, or the
use to which the information is to be put.
d. Check "Reinstatement without change"
when the collection previously had OMB
approval, but the approval as expired or was
withdrawn before this submission was made,
and there is not change to the collection.
e. Check "Reinstatement with change" when
the collection previously has OMB approval,
but the approval has expired or was withdrawn before this submission was made, and
there is change to the collection.
f. Check "Existing collection in use without
OMB control number" when the collection is
currently in use but does not have a currently
valid OMB control number.

4.

Type of review requested (check one)

Small entities

7.

a. Check "Three years" if the agency requests
a three year approval for the collection.

c. Enter the total annual recordkeeping and
reporting hour burden.

b. Check "Other" if the agency requests
approval for less than three years. Specify
the month and year of the requested expiration
date.

d. Enter the burden hours currently approved
by OMB for this collection of information.
Enter zero (0) for any new submission or for
any collection whose OMB approval has
expired.

Title

Agency form number(s) (if applicable)

Keywords
Select and list at least two keywords (descriptors) from the "Federal Register Thesaurus of
Indexing Terms" that describe the subject
area(s) of the information collection. Other
terms may be used but should be listed after
those selected from the thesaurus. Separate
keywords with commas. Keywords should
not exceed two lines of text.

10. Abstract
Provide a statement, limited to five lines of
text, covering the agency's need for the information, uses to which it will be put, and a
brief description of the respondents.
11. Affected public
Mark all categories that apply, denoting the
primary public with a "P" and all others that
apply with "X".
12. Obligation to respond

a. Check "Regular" when the collection is
submitted under 5 CFR 1320.10, 1320.11,
or 1320.12 with a standard 60 day review
schedule.

Mark all categories that apply, denoting the
primary obligation with a "P" and all others
that apply with "X".
a. Mark "Voluntary" when the response is
entirely discretionary and has no direct effect
on any benefit or privilege for the respondent.

b. Check "Emergency" when the agency is
submitting the request under 5 CFR 1320.13
for emergency processing and provides the
required supporting material. Provide the date
by which the agency requests approval.

b. Mark "Required to obtain or retain benefits" when the response is elective, but is
required to obtain or retain a benefit.

c. Check "Delegated" when the agency is
submitting the collection under the conditions
OMB has granted the agency delegated
authority.

b. Enter the number of responses provided
annually. For recordkeeping as compared to
reporting activity, the number of responses
equals the number of recordkeepers.

Requested expiration date

Provide any form number the agency has
assigned to this collection of information.
Separate each form number with a comma.
9.

a. Enter the number of respondents and/or
recordkeepers. If a respondent is also a recordkeeper, report the respondent only once.

b1. Enter the estimated percentage of responses that will be submitted/collected electronically using magnetic media (i.e., diskette),
electronic mail, or electronic data interaction.
Facsimile is not considered an electronic
submission.

Provide the official title of the information
collection. If an official title does not exist,
provide a description which will distinguish
this collection from others.
8.

13. Annual reporting and recordkeeping
hour burden

c. Mark "Mandatory" when the respondent
must reply or face civil or criminal sanctions.

e. Enter the difference by subtracting line d
from line c. Record a negative number (d larger than c) within parentheses.
f. Explain the difference. The difference in
line e must be accounted for in lines f1 and f2.
f1. "Program change" is the result of deliberate Federal government action. All new collections and any subsequent revision of existing collections (e.g. the addition or deletion of
questions) are recorded as program changes.
f2. "Adjustment" is a change that is not the
result of a deliberate Federal government
action. Changes resulting from new estimates
or actions not controllable by the Federal government are recorded as adjustments.
14. Annual reporting and recordkeeping cost
burden (in thousands of dollars)
The costs identified in this item must exclude
the cost of hour burden identified
in Item 13.
a. Enter total dollar amount of annualized
cost for all respondents of any associated capital or start-up costs.
b. Enter recurring annual dollar amount of
cost form all respondents associated with operating or maintaining systems or purchasing
services.
c. Enter total (14a + 14b) annual reporting
and recordkeeping cost burden.
d. Enter any cost burden currently approved
by OMB for this collection of information.
Enter zero (0) if this is the first submission
after October 1, 1995.
e. Enter the difference by subtracting line d
from line c. Record a negative number (d larger than c) within parentheses.
f. Explain the difference. The difference in
line e must be accounted for in lines f1 and f2.
f1. "Program change" is the result of deliberate Federal government action. All new collections and any subsequent revision or
changes resulting in cost changes are recorded
as program changes..
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f2. "Adjustment" is a change that is not the
result of a deliberate Federal government
action. Changes resulting from new estimations or actions not controllable by the Federal
government are recorded as adjustments.
15. Purpose of information collection
Mark all categories that apply, denoting the
primary purpose with a "P" and all others that
apply with "X".
a. Mark "Application for benefits" when the
purpose is to participate in, receive, or qualify
for a grant, financial assistance, etc, from a
Federal agency or program.
b. Mark "Program evaluation" when the purpose is a formal assessment, through objective
measures and systematic analysis, of the manner and extent to which Federal programs
achieve their objectives or produce other
significant effects.
c. Mark "General purpose statistics" when
the data is collected chiefly for use by the
public or for general government use, without
primary reference to the policy or program
operations of the agency collecting the data.
d. Mark "Audit" when the purpose is to verify the accuracy of accounts and records.
e. Mark "Program planning or management"
when the purpose relates to progress reporting
and grants management, procurement and

qualify control or other administrative
information that does not fit into any other
category.
f. Mark "Research" when the purpose is to
further the course of research, rather than for
a specific program purpose.
g. Mark "Regulatory or compliance" when
the purpose is to measure compliance with
laws or regulations.
16. Frequency of recordkeeping or reporting
Check "Recordkeeping" if the collection of
information explicitly includes a recordkeeping requirement.
Check "Third party disclosure" if a collection
of information includes third-party disclosure
requirements as defined by 1320.3 (c).
Check "Reporting" for information collections
that involve reporting and check the frequency
of reporting that is requested or required of a
respondent. If the reporting is on "an event
basis", check "On occasion".
17. Statistical methods
Check "Yes" if the information collection
uses statistical methods such as sampling or
imputation. Generally, check "No" for applications and audits (unless a random auditing
scheme is used). Check "Yes" for statistical
collections, most research collections, and scientific program evaluations. For other types of

data collection, the use of sampling, imputation, or other statistical estimation techniques
should dictate the response for this item.
Ensure that supporting documentation is provided in accordance with Section B of the
Supporting Statement.
18. Agency contact
Provide the name and telephone number of
the agency person best able to answer questions regarding the content of this submission.
19. Certification for Paperwork Reduction
Act Submission
The Senior Official or designee signing this
statement certifies that the collection of information encompassed by the request complies
with 5 CFR 1320.9. Provisions of this certification that the agency cannot comply with
should be identified and fully explained in
item 18 of the attached Supporting Statement.
NOTE: The Office that "develops" and
"uses" the information to be collected is the
office that "conducts or sponsors" the collection of information. (See 5 CFR 1320.3(d).

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Supporting Statement for Paperwork Reduction Act Submissions
General Instructions
A Supporting Statement, including the text of the
notice to the public required by 5 CFR
1320.5(a)(i)(iv) and its actual or estimated date of
publication in the Federal Register, must
accompany each request for approval of a
collection of information. The Supporting
Statement must be prepared in the format described
below, and must contain the information specified
in Section A below. If an item is not applicable,
provide a brief explanation. When Item 17 of the
OMB Form 83-I is checked "Yes", Section B of the
Supporting Statement must be completed. OMB
reserves the right to require the submission of
additional information with respect to any request
for approval.

•

requiring respondents to retain records.
other than health, medical, government
contract, grant-in-aid, or tax records for
more than three years;

•

in connection with a statistical survey, that
is not designed to produce valid and
reliable results that can be generalized to
the universe of study;

•

requiring the use of a statistical data
classification that has not been reviewed
and approved by OMB;

•

that includes a pledge of confidentiality
that is not supported by authority
established in statue or regulation, that is
not supported by disclosure and data
security policies that are consistent with the
pledge, or which unnecessarily impedes
sharing of data with other agencies for
compatible confidential use; or

•

requiring respondents to submit
proprietary trade secret, or other
confidential information unless the agency
can demonstrate that it has instituted
procedures to protect the information's
confidentiality to the extent permitted by
law.

Specific Instructions
A. Justification
1.

2.

3.

4.

Explain the circumstances that make the
collection of information necessary. Identify
any legal or administrative requirements that
necessitate the collection. Attach a copy of
the appropriate section of each statute and
regulation mandating or authorizing the
collection of information.
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.
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 adoption this
means of collection. Also describe any
consideration of using information
technology to reduce burden.

If the collection of information impacts small
businesses or other small entities (Item 5 of
OMB Form 83-I), describe any methods used
to minimize burden.

6.

Describe the consequence to 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.
Explain any special circumstances that would
cause an information collection to be
conducted in a manner:
• requiring respondents to report
information to the agency more often
than quarterly;
• requiring respondents to prepare a
written response to a collection of
information in fewer than 30 days after
receipt of it;
• requiring respondents to submit more
than an original and two copies of any
document;

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. Specifically
address comments received on cost and hour
burden.
Describe efforts to consult with persons
outside the agency to obtain their views on the
availability of data, frequency of collection,
the clarity of instructions and record keeping,
disclosure, or reporting format (if any), and on
the data elements to be recorded, disclosed, or
reported.

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.

5.

7.

8.

12.

13.

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 conduct
special surveys to obtain information on
which to base hour burden estimates.
Consultation with a sample (fewer than
10) of potential respondents is desirable.
If the hour burden on respondents is
expected to vary widely because of
differences in activity, size, or
complexity, show the range of estimated
hour burden, and explain the reasons for
the variance. Generally, estimates should
not include burden hours for customary
and usual business practices.

•

If this request for approval covers more
than one form, provide separate hour
burden estimates for each form and
aggregate the hour burdens in Item 13 of
OMB Form 83-I.

•

Provide estimates of annualized cost to
respondents for the hour burdens for
collections of information, identifying
and using appropriate wage rate
categories. The cost of contraction out or
paying outside parties for information
collection activities should not be
included here. Instead, this cost should
be included in Item 14.

Provide an estimate of the total annual cost
burden to respondents or record keepers
resulting from the collection of information.
(Do not include the cost of any hour burden
shown in Items 12 and 14).
•

The cost estimate should be split into
two components: (a) a total capital and
start-up cost component (annualized over
its expected useful life); and (b) a total
operation and maintenance and purchase
of services component. The estimates
should take into account costs associated
with generating, maintaining, and
disclosing or providing the information.
Include descriptions of methods used to
estimate major cost factors including
system and technology acquisition,
expected useful life of capital equipment,
the discount rate(s), and the time period
over which costs will be incurred.
Capital and start-up costs include,
among other items, preparations for
collecting information such as
purchasing computers and software;
monitoring, sampling, drilling and
testing equipment; and record storage
facilities.

•

If cost estimates are expected to vary
widely, agencies should present ranges of
cost burdens and explain the reasons for
the variance. The cost of purchasing or
contracting out information collection
services should be a part of this cost
burden estimate. In developing cost
burden estimates, agencies may

Consultation with representatives of those
from whom information is to be obtained or
those who must compile records should occur
at least once every 3 years-even if the
collection of information activity is the same
as in prior periods. There may be
circumstances that may preclude consultation
in a specific situation. These circumstances
should be explained.
9.

Explain any decision to provide any payment
or gift to respondents, other than
re-enumeration of contractors or grantees.

10.

Describe any assurance of confidentiality
provided to respondents and the basis for the
assurance in statute, regulation, or agency
policy.

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.

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consult with a sample of respondents
(fewer than 10), utilize the 60-day
pre-OMB submission public comment
process and use existing economic or
regulatory impact analysis associated with
the rulemaking containing the information
collection as appropriate.
•

14.

15.

16.

Generally, estimates should not include
purchases of equipment or services, or
portions thereof, made: (1) prior to
October 1, 1995, (2) to achieve
regulatory compliance with requirements
not associated with the information
collection, (3) for reasons other than to
provide information or keep records for
the government, or (4) as part of
customary and usual business or private
practices.
Provide estimates of annualized cost to the
Federal government. Also, provide a
description of the method used to estimate
cost, which should include quantification of
hours, operational expenses (such as
equipment, overhead, printing, and support
staff), and any other expense that would not
have been incurred without this collection of
information. Agencies also may aggregate
cost estimates from Items 12, 13, and 14 in a
single table.

17.

18.

•

Explain each exception to the certification
statement identified in Item 19,
"Certification for Paperwork Reduction Act
Submissions," of OMB Form 83-I.

•

B. Collections of Information Employing
Statistical Methods

•
•

•

1.

2.

Describe (including a numerical estimate) the
potential respondent universe and any
sampling or other respondent selection
method to be used. Data on the number of
entities (e.g., establishments, State and local
government units, households, or persons) in
the universe covered by the collection and in
the corresponding sample are to be provided
in tabular form for the universe as a whole
and for each of the strata in the proposed
sample. Indicate expected response rates for
the collection as a whole. If the collection had
been conducted previously, include the actual
response rate achieved during the last
collection.
Describe the procedures for the collection of
information including:

Statistical methodology for stratification
and sample selection,
Estimation procedure,
Degree of accuracy needed for the
purpose described in the justification,
Unusual problems requiring specialized
sampling procedures, and
Any use of periodic (less frequent than
annual) data collection cycles to reduce
burden.

3.

Describe methods to maximize response rates
and to deal with issues of non-response. The
accuracy and reliability of information
collected must be shown to be adequate for
intended uses. For collections based on
sampling, a special justification must be
provided for any collection that will not yield
"reliable" data that can be generalized to the
universe studied.

4.

Describe any tests of procedures or methods
to be undertaken. Testing is encouraged as an
effective means of refining collections of
information to minimize burden and improve
utility. Tests must be approved if they call for
answers to identical questions from 10 or
more respondents. A proposed test or set of
tests may be submitted for approval
separately or in combination with the main
collection of information.

5.

Provide the name and telephone number of
individuals consulted on statistical aspects of
the design and the name of the agency unit,
contractor(s), grantee(s), or other person(s)
who will actually collect and/or analyze the
information for the agency

The agency should be prepared to justify its decision
not to use statistical methods in any case where such
methods might reduce burden or improve accuracy
of results. When Item 17 on the Form OMB 83-I is
checked "Yes", the following documentation should
be included in the Supporting Statement to the
extent that it applies to the methods proposed:

Explain the reasons for any program changes
or adjustments reported in Items 13 or 14 of
the OMB Form 83-I
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 of information, completion
of report publication dates, and other actions.

If seeking approval to not display the
expiration date for OMB approval of the
information collection, explain the reasons
that display would be inappropriate.

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