Authorization for Release of Medical Information for Black Lung Benefits

Forms and Documents

Document Name	Status
Form CM-936 Authorization for Release of Medical Information Form	Modified
Supporting Statement 1240-0034 (CM-936).doc Supporting Statement A	2012-07-31
725.405.pdf Supplementary Document	2006-08-09
30 USC Sec. 902.pdf Supplementary Document	2006-08-09
30 USC Sec. 901.pdf Supplementary Document	2006-08-09
30 Chapter 22.pdf Supplementary Document	2006-08-09
DOL-ESA-30.pdf Supplementary Document	2006-08-09
DOL-ESA-6.pdf Supplementary Document	2006-08-09

IC Document Collections

IC ID	Document Title	Status
13694	Authorization for Release of Medical Information Form	Modified

ICR Details

OMB Control No: 1240-0034	ICR Reference No: 201207-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-034
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Authorization for Release of Medical Information for Black Lung Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/23/2012
	Date Received in OIRA: 09/14/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	36 Months From Approved	11/30/2012
Responses	900	0	900
Time Burden (Hours)	75	0	75
Cost Burden (Dollars)	0	0	0

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Abstract: The CM-936 is used to obtain the black lung claimant's authorization for the Division of Coal Mine Workers' Compensation to request medical evidence in support of the black lung claim.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 32140	05/31/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 56869	09/14/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Authorization for Release of Medical Information	CM-936	Authorization for Release of Medical Information (Black Lung)

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	900	900	0	0	0	0
Annual Time Burden (Hours)	75	75	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $3,671

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/14/2012

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