SUPPORTING STATEMENT
CM-623, REPRESENTATIVE PAYEE REPORT
CM-623S, REPRESENTATIVE PAYEE REPORT (Short Form)
CM-787, PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT
OMB No. 1240-0020
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.
CM-623 and CM-623S
Benefits due a DOL black lung beneficiary may be paid to a representative payee on behalf of the beneficiary when the beneficiary is unable to manage his/her benefits due to incapability, incompetence or minority. The CM-623 (Representative Payee Report) form is used to collect expenditure data regarding the disbursement of the beneficiary's benefits by the payee to assure that the beneficiary's needs are being met. The Federal Mine Safety and Health Act (30 U.S.C. 901) and 20 CFR 725.510, 511, and 513 necessitate this information collection. The CM-623 is used to ensure that benefits paid to the representative payee are used for the beneficiary’s care and well being. The submission of the CM-623 is required to obtain and retain benefits and failure to complete and file this form may prevent payment of benefits.
The CM-623S, Representative Payee Report (Short Form) is sent to representative payees who are relatives of and who live with the beneficiary. The CM-623S requires less detailed certification from the representative payee than the CM-623 requires. The CM-623S was developed because relatives of the beneficiary who live with him/her felt that to have to complete the regular form CM-623 was an unwarranted burden, since the regular form requires such detailed verification. To have to complete a form in such detail by someone who is a close family member and who apparently has the beneficiary's best interests in mind seemed unnecessarily burdensome for this category of representative payee. The CM-623S is used when the representative payee is a family member residing with the beneficiary to ensure that benefits paid to the representative payee are used for the beneficiary’s care and well being. The submission of the CM-623S is required to obtain and retain benefits and failure to complete and file this form may prevent payment of benefits.
CM-787
In certain instances, benefits due a DOL black lung beneficiary may be paid to another person on behalf of the beneficiary when the beneficiary is unable to meet his/her needs due to incapability or incompetence. To determine incapability or incompetence, certain medical information needs to be obtained from a physician. In a small percentage of representative payee cases the CM-787 is needed to determine the capability of a beneficiary to manage monthly benefits. The Federal Mine Safety and Health Act of 1977 (30 U.S.C. 922) and 20 CFR 725.506 necessitate this information. The CM-787 is used to help determine if the beneficiary requires assistance in managing his/her benefits because of impairment.
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.
CM-623 and CM-623S
The representative payee reports to the Division of Coal Mine Workers’ Compensation (DCMWC) the utilization of yearly benefits received on behalf of the beneficiary. The claims examiner reviews the form and determines if the representative payee is providing for the beneficiary's current needs with the funds certified to the representative payee, if any excess monies remain, and if the funds have been properly conserved for the beneficiary's future needs. If no reporting and accounting were required, the DCMWC would have no way of knowing if a representative payee is properly using the beneficiary's money to provide for the beneficiary's care and keeping. This could result in potential fraud and abuse.
CM-787
If the District Director has reason to believe that a beneficiary may not be able to manage his/her benefits, and if medical information is needed to help determine the beneficiary's incapability, the patient's physician or a medical officer is requested to report the beneficiary's capability to manage benefits to DCMWC on a one time only basis or, as appropriate, if the beneficiary later becomes capable to manage benefits. Without the CM-787, the claims examiner would have no uniform way of requesting this type of medical information.
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.
CM-623, CM-623S and CM-787
In accordance with the Government Paperwork Elimination Act (GPEA), the CM-623, CM-623s, and CM-787 in this information collection were considered but found to be not practicable for electronic submission. In the OWCP Black Lung GPEA Forms Final Transformation Status report, OWCP determined that the three forms should not be made available for electronic submission.
All three forms are currently available on the Internet for downloading, on-screen filling, and printing at: http://www.dol.gov/owcp/regs/compliance/cm-623.pdf, http://www.dol.gov/owcp/regs/compliance/cm-623s.pdf; http://www.dol.gov/owcp/regs/compliance/cm-787.pdf.
The CM-623 and CM-623s contain space for the signature of a witness if the person completing the form 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 electronic address other than the Department’s designated electronic mailbox. This would prevent the payee from forwarding the form to the witness after both had received their digital signature verification keys. The CM-787 is similarly fillable only. Although there is no space for a witness, the form is pre-filled by the claims examiner with the beneficiary’s name, address, and identifying information before it is mailed to the physician for completion and signature.
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.
CM-623, CM-623S and CM-787
We have reviewed all of our forms and determined that there is no form analogous to the CM-623, CM-623s, and CM-787. The Social Security Administration uses a similar form, the SSA-788, to assure proper usage of benefits, to determine if the beneficiary's needs are being met and to account for monies certified to the representative payee. DCMWC cannot use the SSA form because DCMWC and SSA have different beneficiary populations and because the SSA form does not include appropriate references to the Black Lung Benefits Act.
5. If the collection information impacts small businesses or other small entities (Item 5 of 014B Form 83-1), describe any methods used to minimize burden.
CM-623
Small businesses such as nursing homes, long-term care facilities, boarding houses, etc. would be involved. If the beneficiary were a resident in that type of institution and that institution were appointed the representative payee, the institution's administrator would be required to give an accounting of the use of the beneficiary's benefits. The only burden would be the completion of the CM-623 form. Since the information needed for completion should be part of the small business's regular accounting procedure, and is only required on occasion, the government's efforts to minimize burden for small businesses have been considered.
CM-623S
Since this form will only be completed by a relative living with the beneficiary, there are no small businesses involved.
CM-787
Small businesses such as physicians are involved. The only burden is the completion of a short form. The medical information, for the most part, is already a matter of record and the physician would affirm the facts for DOL/DCMWC records.
There is no significant economic impact on a substantial number of small entities.
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.
CM-623 and CM-623S
DCMWC will mail the report to the appropriate representative payee when necessary. Annual reporting is accomplished on OMB 1240-0173, while the CM-623 and CM-623S will be used on those occasions when an additional report is necessary, such as a change in representative payee or a final accounting following the death of a beneficiary. If final reporting were not done, the potential for fraud and abuse would increase as representative payees would not be held accountable for use of the beneficiary's monies.
CM-787
DCMWC mails the request for the physician's statement on a one-time basis for the most part. The physician's response is brief for pertinent information. If this information were not obtained, there would not be any other means to determine the beneficiary's capability to manage benefits from a medical view.
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.
CM-623, CM-623S & CM-787
There are no applicable special circumstances for conducting 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.
CM-623 and CM-623S
The SSA-788’s predecessor form, SSA-623, was used as a prototype in the development of the black lung forms. The CM-623 expands upon the SSA form to capture more detailed expenditure information to ensure proper use of the beneficiary's funds and identify potential fraud and abuse. The CM-623S requests less information than the SSA form and is sent only to a representative payee who is a relative of the beneficiary and lives with the beneficiary.
CM-787
The CM-787 is used by DCMWC to obtain a medical professional’s opinion concerning the capacity of a beneficiary to manage his/her own benefits.
A Federal Register Notification inviting public comment was published on May 3, 2011 in Vol. 76, No. 85, page 24919. No comments were received.
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.
CM-623, CM-623S & CM-787
The Privacy Act System (ESA-6 and ESA-30) provides confidentiality of information collection involving a claimant's records.
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.
CM-623, CM-623S & CM-787
There are no questions of a sensitive nature on these forms.
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.
CM-623
An average of 900 CM-623 forms will be sent annually to representative payees who are not family members residing with beneficiaries. It takes these representative payees approximately one and 1/2 hours to complete the form and mail it. This results in 1,350 burden hours.
CM-623S
An average of 100 CM-623S forms will be sent annually to representative payees who are family members of, and who live with, beneficiaries. It takes these representative payees approximately 10 minutes to complete the form and mail it. This results in 17 burden hours.
CM-787
An average of 1,100 CM-787 forms are sent annually to physicians. It takes the physician approximately 15 minutes to complete the form and mail it. This results in 275 burden hours.
Total burden hours for the CM-623, CM-623S and CM-787 are:
CM-623 1,350
CM-623S 17
CM-787 275
Total 1,642 burden hours
We estimate the annualized cost for the burden hours to 90% of the CM-623 and CM-623S respondents, individuals and family members, by applying the minimum wage per hour of $7.25.
We estimate the annualized cost to 10% of the CM-623 respondents by applying the hourly wage of $16.99 for bookkeeping and accounting clerks taken from the May 2010 National Occupational Employment and Wage Estimates, published by the Bureau of Labor Statistics at
http://www.bls.gov/oes/current/oes433031.htm.
We estimate the annualized cost to the CM-787 respondents by applying the hourly wage of $86.96 for physicians, taken from the May 2010 National Occupational Employment and Wage Estimates, published by the Bureau of Labor Statistics at http://www.bls.gov/oes/current/oes291069.htm.
CM-623 1,215 hours x $7.25 = $8,808.75
CM-623 135 hours x $16.99 = $2,293.65
CM-623S 17 hours x $7.25 = $ 123.25
CM-787 275 hours x $86.96 =$23,914.00
The total annualized burden cost for respondents is $35,139.65.
Annual Costs to Respondents (capital/start-up & operation and maintenance).
There are no operation and maintenance costs associated with the collection of the three forms. Return postage is provided.
14. Provide estimates of annualized cost to the Federal government.
The total Federal cost estimate for the three forms is
estimated at $ 28,883.55.
CM-623
The Federal cost estimate of $17,311.50 was determined for an average annual usage of 900 forms as follows:
o printing 900 x $.08 per form = $ 72.00
o mailing 900 x $.47 per form = $ 423.00
$.44 postage plus $.03 envelope
o processing A GS-12/5-RUS (from OPM Salary Tables) ($37.37 per hour) spends 30 minutes processing each form.
900 forms x 1/2 hour = 450 hours
450 hours x $37.37 = $16,816.50
CM-623S
The Federal cost estimate of $690.30 was determined for an average annual usage of 100 forms as follows:
o printing 100 x $.08 per form = $ 8.00
o mailing 100 x $.47 per form = $ 47.00
$.44 postage plus $.03 envelope
o processing A GS-12/5 ($37.37 per hour) spends 10 minutes processing each form.
100 forms x 1/6 hour = 17 hours
17 hours x $37.37 = $635.30
CM-787
The Federal cost estimate of $10,881.75 was determined for an average annual usage of 1,100 forms as follows:
o printing 1,100 x $.08 per form = $ 88.00
o mailing 1,100 x $.47 per form = $ 517.00
$.44 postage plus $.03 envelope
o processing A GS-12/5 ($37.37 per hour) spends 15 minutes processing each form.
1,100 forms x 15 minutes = 275 hours
275 hours x $37.37= $10,276.75
15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.
There have been no program changes or adjustments. The number of total respondents remains 2,100 and the burden hours 1,642.
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 for publishing statistical data based on this information collection.
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 request 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-I.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods
Statistical methods are not used in these collections of information.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | nofpw |
| Last Modified By | yferguso |
| File Modified | 2011-09-15 |
| File Created | 2011-09-15 |