Supporting Statement Cm-908

SUPPORTING STATEMENT

CM-908 Notice of Termination, Suspension, Reduction, or Increase in Benefit Payments

OMB No. 1240-0030

1. 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.

Coal mine operators, their representatives, or their insurers who have been identified as responsible for paying Black Lung benefits to an eligible miner or an eligible surviving dependent of the miner, are called Responsible Operators (RO’s). RO’s that pay benefits are required to report any change in the benefit amount to the Department of Labor (DOL). The CM‑908, when completed and sent to DOL, notifies DOL of the change in the beneficiary's benefit amount and the reason for the change. The Federal Mine Safety and Health Act of 1977 as amended, Section 432(30 U.S.C. 942) and 20 CFR 725.621 necessitate this information collection.

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.

20 CFR 725.621 requires that this form be completed in full and filed with the Office of Workers’ Compensation Programs within 16 days following the termination of benefits and immediately following suspension, reduction or increase of benefits paid under Title IV of the Federal Mine Safety and Health Act of 1977, as amended, to insure that the correct benefits are paid.

The RO reports changes in the beneficiary's monthly benefits and explains the reason for that change. A claims examiner reviews the information to ensure that the Division of Coal Mine Workers' Compensation (DCMWC) regulations are followed correctly, that the new benefit amount is accurate, and that the date of change in benefits accurately corresponds to the date of the event requiring the change. If this information were not gathered, there would be no way to insure that Black Lung beneficiaries who receive benefit payments from ROs are receiving the correct amount of benefits.

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.

Many RO’s have automated the information process when reporting changes in benefit amounts. This information is submitted using the CM-908 form.

The form had been considered for electronic submission, but it is a three-part form in which the original is sent to DCMWC, one copy is sent to the payee, and another is retained by the sender. As such, the form is unsuitable for electronic submission, but it is available for downloading from the DCMWC web site by respondents at http://www.dol.gov/owcp/regs/compliance/cm-908.pdf.

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 is no similarly approved information collection used by the program or Federal Government for RO reports of changes in monthly benefit payments. Similar information is not available concerning RO payments to beneficiaries.

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.

Although some coal mine operators and insurers qualify as small businesses, this information collection 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.

Since this information is collected only at the time a change occurs, DCMWC would not be notified of a change in benefits if this information were collected less frequently. This might create hardships to RO’s and beneficiaries because of undiscovered overpayments and underpayments.

7.         Explain any special circumstances that would cause an information collection to be conducted in a manner:

20 CFR 725.621 requires that this form be filed in the office of the District Director within 16 days of termination of benefits by the responsible coal mine operator or insurer. One purpose of this abbreviated reporting period is to give the District Director the opportunity to ascertain if benefits should continue from another source, such as the Black Lung Disability Trust Fund, if the cause of termination was not the death of the beneficiary but another cause, such as the employer’s bankruptcy. A second purpose is to give the District Director the opportunity to verify the beneficiary’s death and, if appropriate, initiate benefits to eligible survivors without undue delay.

It should also be noted that this information collection is not sent to the operator or insurer by DOL for completion and return. The operator or insurer initiates the report when it changes or terminates benefits to an individual. The claim form is available online and upon request, but in most cases has been preformatted for use in the insurers’ computer systems so that a change in benefits automatically generates a CM-908 report form.

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.

A Federal Register Notice inviting public comment was published on March 7, 2012 in Vol. 77, No. 45, page 13636. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts are provided to respondent.

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

Not applicable. Respondents are not individuals covered by the Privacy Act of 1974.

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 a sensitive nature.

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 public burden estimate of this information collection is approximately 1,000 hours. This burden is based on the submission of 5,000 forms. About 4,200 beneficiaries currently receive benefits from approximately 325 RO’s. RO’s complete one CM-908 per beneficiary for cost-of-living increase plus an annual average of approximately 800 forms for reporting changes in dependency, death of the beneficiary, or change in other workers’ compensation that affect the benefit amount. Each response averages 12 minutes for retrieving information and completing and mailing the form, for a total of approximately 1,000 hours.

4,200 forms + 800 forms = 5,000 forms

5,000 forms x 12 minutes = 1,000 hours

The estimated annualized cost to respondents to provide this information is $16,090.00 (1,000 hours x $16.09 per hour). This hourly wage is taken from the Occupational Earnings Tables: United States, December 2009 – January 2011 (average reference date July 2010), published by the Bureau of Labor Statistics, http://www.bls.gov/ncs/ocs/sp/nctb1475.pdf, page 8, under the heading of Office and Administrative Support ($16.09 per hour average).

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

The cost to respondents to mail their response is estimated at 96¢ per response (45¢ stamp plus 03¢ for the envelope) to two recipients, DCMWC and the beneficiary, for a total respondent cost of $4,800.00 (96¢ x 5,000 responses). There are no other known operating or maintenance costs associated with this collection.

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

The estimated total cost to the Federal Government for these 5,000 forms is approximately $40,812.50. The cost is calculated as follows:

a. Estimated printing cost: $400.00

b. Estimated mailing cost: $700.00; this form is bulk mailed to RO’s; cost is about $.10 per form.

c. The estimated processing cost: $40,812.50 figured at one CE (GS-12/04) spending about 15 minutes evaluating one form. (The Salary Table 2012-GS was used for the hourly wages.)

5000 x .25 = 1,250 hours

$31.77 x 1,250 hrs = $39,712.50

Total Cost: $400 + $700 + $39712.50 = $40,812.50

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

Annual costs to respondents (Item 13) increased slightly because of increases in postage rates. However, this has been offset due to an adjustment in the number of responses (2000 less than the previous clearance). This adjustment was caused by a reduction in the number of beneficiaries for whom responses are required.

While not expected to change respondent burden, this ICR has been characterized as a revision because the agency has reformatted elements of Form CM-908 (e.g., replaced an obsolete logo with the DOL Seal, OMB Control Number, additional notice on rights for persons with disabilities, and removed references to the no longer existent Employment Standards Administration). Upon OMB’s clearance of this request OWCP will update the form to show the new.

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 collection 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.

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