Supporting Statement for 1240-0038

SUPPORTING STATEMENT

CM‑911, Miner's Claim for Benefits under the Black Lung Benefits Act

CM‑911a, Employment History

OMB No. 1240-0038

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‑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. 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‑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. 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 accordance with GPEA requirements, the forms CM‑911, CM‑911a are available for downloading at:

http://www.dol.gov/owcp/regs/compliance/cm-911.pdf

http://www.dol.gov/owcp/regs/compliance/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. 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.

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. 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.

Collection of this information does not have a 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.

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. 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 collecting this information.

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.

Consultations with respondents take place at any time a question or problem is raised.

A Federal Register Notice inviting public comment was published on May 3, 2011, in Vol. 76, No. 85, Page 24918. 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 any 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.

Privacy Act System Notice ESA‑6 provides for confidentiality of information collection involving a claimant's record.

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.

There are no questions of sensitive nature in 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. Provide estimates of the hour burden of the collection of information.

CM‑911

The estimated burden of this information collection is approximately 3,000 hours. This burden is based on a submission of 4,000 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 4,000 forms = 3,000 total burden hours.

For the burden cost to the applicant, we use the minimum wage of $7.25 per hour.

3,000 burden hours x $7.25 per hour = $21,750

CM‑911a

The estimated burden of this information collection is approximately 3,667 hours. This burden is based on a submission of 5,500 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 5,500 forms = 3,667 total burden hours.

For the burden cost to the applicant, we use the minimum wage of $7.25 per hour.

3,667 burden hours x $7.25 per hour = $26,586

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

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% (3,850) 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 $1,449.00 to $1,771.00 due to the increased number of respondents. The total respondent cost is $1,771.00. The cost is figured as follows:

CM-911: no cost

CM-911a: 3,850 x .46 = $1,771.00

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

CM‑911

The estimated total cost to the Federal Government for 4,000 CM‑911's is approximately $75,290.00.

a. Estimated printing cost: $550.00

b. Estimated mailing cost: None - Forms obtained from Black Lung or Social Security District Office.

c. Estimated processing cost: $74,740.00

GS‑12/5 spends about 30 minutes per form for review

$37.37 x .50 x 4,000 = $74,740.00 (GS-12/5 RUS salary from OPM Salary Table)

CM‑911a

The estimated total cost to the Federal government for 5,500 CM‑911a's is approximately $104,332.50.

a. Estimated printing cost: $300.00

b. Estimated mailing cost: $1,265.00

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% (2,750) 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 $1,265.00. The cost is figured as follows:

CM-911: no cost

CM-911a: 2,750 x .46 = $1,265.00

c. Estimated processing cost: $102,767.50

GS‑12/5 spends about 30 minutes per form for review

$37.37 x .50 x 5,500 = $102,767.50

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

There is an adjustment of respondents from 7,500 to 9,500 because there has been an increase in black lung applicants following enactment of new laws in 2010. The burden hour is an adjustment from 5,250 to 6,667 which is a difference of 1,417 burden hours. There has been an increase to the maintenance and operation cost from $1,449.00 to $1,771.00 due to an increase in postage.

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 collection of 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-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.