SUPPORTING STATEMENT
CM‑911, Miner's Claim for Benefits under the Black Lung Benefits Act
CM‑911a, Employment History
OMB No. 1215-0052
A. Justification.
1. CM‑911
Title IV of the Federal Mine Safety and Health Act of 1977 as amended by the Black Lung Benefits Reform Act of 1977 and subsequent amendments, 30 USC 901 et. seq., provides for the payment of benefits to a coal miner who is totally disabled due to pneumoconiosis (black lung disease) and to certain survivors of the miner who died due to pneumoconiosis.
A miner who applies for black lung benefits must complete the CM‑911 (application form). The completed form gives basic identifying information about the applicant and is the beginning of the development of the black lung claim. The Black Lung Benefits Act as amended, 30 USC 901 et. seq., and 20 CFR 725.304a, necessitates the collection of this information.
CM‑911a
An applicant filing for black lung benefits must complete a CM‑911a at the same time the black lung application form is submitted. This form when completed is formatted to render a complete history of employment and helps to establish if the miner currently or formerly worked in the nation's coal mines. The person filing for benefits must have worked in the nation's coal mines or be a survivor of a coal miner as described under Title IV of the Federal Mine Safety and Health Act of 1977, as amended, in order for benefits to be pursued. The Black Lung Benefits Act, as amended and 20 CFR 725.404(a) necessitates the collection of this information.
The collection of the coal miner’s Social Security number is necessary because of offset provisions in the laws for both the Social Security Administration and Black Lung in order to prevent overpayments and duplicate benefits. DCMWC masks the SSN on all outgoing correspondence so that all digits except the last four appear as X.
The SSN is also needed to coordinate medical treatment benefits between the Black Lung Program and other health care insurers to prevent duplicate reimbursement. Also, the universal billing form (CMS-1500) and our version (OWCP-1500) use the SSN, it would be almost impossible to properly pay medical providers for the treatment service given to disabled miners without it.
2. CM‑911
Upon completion by the applicant and receipt of the CM‑911 by the Black Lung District Office, the claims examiner (CE) reviews the information and begins the verification process of each item on the application. For example, the CE requests certified copies of the birth and marriage records to establish dependency and to help determine the potential amount of benefits to which the miner would be entitled. Upon receipt and verification of all items requested, the CE can determine if the applicant meets the statutory criteria for an award of benefits. If this information were not collected and the miner's signature were not obtained on the CM‑911, the requirements of the Black Lung Benefits Act would not be met.
CM‑911a
Once the CM‑911a is completed and received in the black lung office, the CE reviews and verifies the information to determine if coal mine employment is established. Other types of employment are also reviewed to help establish total disability due to coal mine employment. Proof of coal mine employment is a major element in establishing a causal relationship between employment and total disability due to pneumoconiosis for entitlement purposes. If this information were not gathered, neither coal mine employment nor the length of that employment could be established.
3. In accordance with GPEA requirements, the forms CM‑911, CM‑911a are
available for downloading at:
http://www.dol.gov/esa/regs/compliance/owcp/cm-911.pdf
http://www.dol.gov/esa/regs/compliance/owcp/cm-911a.pdf
The forms can be filled out on-screen, printed, and mailed or may be printed, completed by hand, and mailed. However, they have not been made available for electronic submission. Each form requires the signature of the claimant, which could be affixed electronically, but 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 website 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. Since the information requested on each of these forms specifically relates to the Black Lung Program, no other Federal agency has similar requirements. However, there is one item, verification of employment, that may be obtained from the Social Security Administration (SSA). SSA is contacted only if the employment records are not available from the employer. Employer records give more complete history of employment and the reasons why the miner’s employment ended.
5. Collection of this information does not have a significant economic impact on a substantial number of small entities.
6. This information is collected only at the time of application. If it were collected less frequently, this information would not be available for case adjudication.
7. There are no special circumstances for collecting this information.
8. Consultations with respondents take place at any time a question or problem is raised.
A Federal Register Notice inviting public comment was published on April 29, 2008. No comments were received.
9. Respondents do not receive any gifts or payments to furnish the
requested information.
10. Privacy Act System Notice ESA‑6 provides for confidentiality of information collection involving a claimant's record.
11. There are no questions of sensitive nature in these forms.
12. CM‑911
The estimated burden of this information collection is approximately 2,250 hours. This burden is based on a submission of 3,000 CM‑911's with 45 minutes to read and complete the form. The local Social Security Office or Black Lung Office supplies the form and helps the claimant complete the form.
45 minutes x 3,000 forms = 2,250 total burden hours.
For the burden cost to the applicant, we use the minimum wage of $5.85 per hour.
2,250 burden hours x $5.85 per hour = $13,162.50
CM‑911a
The estimated burden of this information collection is approximately 3,000 hours. This burden is based on a submission of 4,500 CM‑911a's with 40 minutes to read and complete the form. The local Social Security Office or Black Lung Office supplies the form and helps the claimant complete the form.
40 minutes x 4,500 forms = 3,000 total burden hours.
For the burden cost to the applicant, we use the minimum wage of $5.85 per hour.
3,000 burden hours x $5.85 per hour = $17,550.00
13. Since the CM-911 and the CM-911a are generally completed and returned at the same time, no additional mailing costs appear for the CM-911. An estimated 70% (3,150) of the respondents mail their response, and the cost is estimated at 46 cents per respondent for postage and envelope. The estimated cost for operations and maintenance has increased from $1000.00 to $1,449.00 due to the increased cost of postage. The total respondent cost is $1,449.00. The cost is figured as follows:
CM-911: no cost
14. CM‑911
The estimated total cost to the Federal Government for 3,000 CM‑911's is approximately $47,460.00.
a. Estimated printing cost: $450.00
b. Estimated mailing cost: None - Forms obtained from Black Lung or Social Security District Office.
c. Estimated processing cost: $47,460.00
GS‑12/5 spends about 30 minutes per form for review
$31.34 x .50 x 3,000 = $47,010.00
CM‑911a
The estimated total cost to the Federal government for 4,500 CM‑911a's is approximately $71,800.
a. Estimated printing cost: $250.00
b. Estimated mailing cost: $1,035.00
Since the CM-911 and the CM-911a are mailed at the same time, no additional mailing costs appear for the CM-911. An estimated 50% (2,250) of the CM-911 and CM-911a are sent to the black lung applicants, and the cost is estimated at 46 cents per applicant for postage and envelope. The total mailing cost is $1,035.00. The cost is figured as follows:
CM-911: no cost
c. Estimated processing cost: $71,550.00
GS‑12/5 spends about 30 minutes per form for review
$31.34 x .50 x 4,500 = $70,515.00
15. There is an adjustment reduction of respondents from 9,000 to 7,500 because there are fewer black lung applicants. The burden hour is an adjustment reduction from 6,333 to 5,250 which is a difference of -1,083 burden hours due to fewer applicants. There has been an increase to the maintenance and operation cost from $1,000.00 to $1,449.00 due to an increase in postage.
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 | Department of Labor |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2008-07-23 |
| File Created | 2008-07-23 |