Supporting Statement for 1240-0032 (CM-905) April 2010

Supporting Statement

CM‑905, Request for State or Federal Compensation Information

OMB No. 1240-0032 (formerly 1215-0060)

A. Justification.

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.

The Federal Mine Safety and Health Act of 1977, as amended (30 U.S.C. 901 et. seq.) and 20 CFR 725.535 require that DOL Black Lung benefit payments to a beneficiary for any month be reduced by any other payments of state or federal benefits for workers' compensation due to pneumoconiosis. To ensure compliance with this mandate, DCMWC must collect information regarding the status of any state or Federal workers' compensation claim, including dates of payments, weekly or lump sum amounts paid, and other fees or expenses paid out for this award, such as attorney fees and related expenses associated with pneumoconiosis. A social security number is mandated for the information collection per Public Law 106-113.

2. 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.

This form is submitted to Federal or state agencies for completion when it is indicated that the beneficiary has filed a claim for workers' compensation benefits due to pneumoconiosis, or is receiving benefits that may need to be offset. State or Federal workers' compensation programs are directed to notify DCMWC of any rate changes or cessation of compensation benefits. Usually only one CM‑905 is sent; however, a second CM‑905 may be sent if the claims examiner suspects recent activity regarding a claimant's state workers' compensation claim, but has no recent CM‑905 information in file. Information is used by DCMWC claims examiners in determining the amounts of black lung benefits paid to beneficiaries. Benefit amounts are reduced, dollar for dollar, for other black lung related workers' compensation awards the beneficiary may be receiving from state or Federal programs.

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.

In the OWCP Black Lung GPEA Forms Final Transformation Status report, OWCP determined that the CM-905 form should not be made available on the Internet because it is initiated by the DCMWC claims examiner 100% of the time.  It is not usable by the state workers’ compensation official unless it contains identifying information supplied by DCMWC.  It requires the signatures of both the claims examiner and the state official.  Because workers’ compensation information is covered by the Privacy Act or similar state privacy statutes, the DCMWC examiner’s personal or digital signature is usually required for the state to release information, and an on-line or PDF form on the DCMWC website would not permit submission to the state workers’ compensation agency.

 

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.

There are no similarly approved forms used within the program. No other ESA program or Federal agency has similar requirements. The collection of this information is specific for workers' compensation benefits due to pneumoconiosis.

5. If the collection information impacts small businesses or other small entities (Item 5 of OMB Form 83-1), describe any methods used to minimize burden.

No small businesses are affected by the collection of this data.

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.

This information is collected only at the time a beneficiary indicates that he has filed an occupational disease claim for pneumoconiosis with a state government or another Federal workers’ compensation program. DCMWC must verify that the claimant filed for Federal or state benefits and any amount of compensation the claimant may receive due to black lung disease. Without this information, an overpayment may occur to the claimant because state benefits offset federal black lung benefits.

7. Explain any special circumstance 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;

• 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 statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentially 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 prove that it has instituted procedures to protect the information's confidentially to the extent permitted by law.

There are no special circumstances for this information collection.

8. 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.

Consultation with state or Federal workers' compensation programs occurs whenever the form is sent out and the response is unclear either to that program or to DOL. No problems have resulted from use of this form.

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 to furnish 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 attached Privacy Act System notices (ESA‑6 & ESA‑30) provide confidentiality of information collection involving Black Lung claimant files and computerized data.

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.

No questions of a sensitive nature appear on this 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.

The public burden estimate of this information collection is approximately 350 hours. The estimated burden is based on the submission of approximately 1400 forms. This represents about 1400 black lung claimants who may have filed occupational disease claims with a state or Federal government. Each response averages 15 minutes per form for a total of 350 hours to collect the data for 1,400 forms.

1400 x 15 minutes = 350 hours

The estimated annualized cost to respondents to provide this information is $8,011.50 (350 hours x $22.89 per hour). The hourly wage of $22.89 is taken from the Establishment Data Earnings Not Seasonally Adjusted B-18 for February 2010 published by the Bureau of Labor Statistics, under the heading of Professional and Business Services (highlighted on attachment.) The table may be found at: ftp://ftp.bls.gov/pub/suppl/empsit.ceseeb18.txt.

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

(a) Total capital and start-up costs: None.

(b) Total operation, maintenance, and purchases of services component:

Estimated mailing costs: $658.00

((44¢ stamp + 3¢ envelope) 47¢ x 1400 = $658.00)

14. Provide estimates of annualized cost to the Federal government.

The estimated cost to the Federal Government for these 1,400 forms is approximately $12,599.50. The cost is figured as follows:

(a) Estimated printing cost: $150.00

(b) Estimated mailing cost: $658.00

(44¢ plus 3¢ per envelope for a total of 47¢ per form)

(c) The estimated processing cost: $11,791.50

(One CE GS‑12/6 spends about 15 minutes evaluating each form or 350 hours ($33.69 x 350 = $11,791.50).

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

There were no program changes or adjustments because the total number of burden hours and the total response has been remained the same. There has been an adjustment of $84.00 to show an increase in cost due to higher postage.

BURDEN HOURS RESPONSES O&M COST

Current inventory 350 1,400 $ 574.00

Requested 350 1,400 $ 658.00

Difference 0 0 $ 0.00

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 to publish this information.

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 ICR 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 83-1.

There are no exceptions to the certification statement.