Certification by School Official

Forms and Documents

Document Name	Status
Form CM-981 Certification By School Official Form	Modified
Supporting Statement 1240-0031 (CM-981).docx Supporting Statement A	2013-04-23
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2010-05-11
725.208 - .209.pdf Supplementary Document	2010-05-11
30 USC 901-902.pdf Supplementary Document	2010-05-11

IC Document Collections

IC ID	Document Title	Status
13706	Certification By School Official Form	Modified

ICR Details

OMB Control No: 1240-0031	ICR Reference No: 201302-1240-002
Status: Historical Active	Previous ICR Reference No: 201005-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Certification by School Official
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: 07/24/2013
	Date Received in OIRA: 05/26/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	07/31/2013
Responses	493	0	300
Time Burden (Hours)	82	0	50
Cost Burden (Dollars)	0	0	0

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Abstract: CM-981 is completed by a school official to verify whether a Black Lung beneficiary's dependent, aged 18 to 23, qualifies as a full-time student.

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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:
	78 FR 12364	02/22/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 31582	05/24/2013
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
Certification By School Official	CM-981	Certification by School Official

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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	493	300	0	0	193	0
Annual Time Burden (Hours)	82	50	0	0	32	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: There is an adjustment to the number of students requiring verification. Previously, estimates were used to determine the number of forms needing completion. An estimate was not used with this year's calculation, but rather actual data. The number of respondents has therefore increased from 300 to 493 and the number of burden hours has increased from 50 hours to 82 hours. This increase has resulted in an adjustment of +32 burden hours.

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Annual Cost to Federal Government: $1,941

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: 05/26/2013

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