SUPPORTING STATEMENT
Certification by School Official (CM-981)
OMB NO. 1240-0031
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.
In order to qualify as an eligible dependent for black lung benefits, a child aged 18 to 23 must be a full-time student as described in the Black Lung Benefits Act, 30 USC 901 et. seq. and attending regulations 20 CFR 725.209. The form CM-981 is used to verify full-time student status.
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.
Once a child aged 18 is identified, the claims examiner (CE) determines if the child is a student and obtains the name and address of the school. The CE completes the upper half of the CM-981 and mails it to the school. The school official completes the remainder, signs it, and returns it to DCMWC. The CE reviews it to insure that the dependent, from the ages of eighteen to twenty-three, is a full-time student. If so, benefits for the dependent continue to be paid. If the dependent is not a full-time student, benefits on behalf of the dependent will be suspended or terminated.
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.
The CM-981 is partially completed by the appropriate district office so that the school official or registrar’s office will know for which student and time period the information is being requested. At the time of request, the appropriate district office address and the telephone number are placed on the form. The partially completed form is sent to the registrar’s office together with a return envelope. The information requested is readily available from the registrar. In accordance with the Government Paperwork Elimination Act (GPEA), this form has also been made available on-line, and may be submitted in one of three different methods if the registrar’s office chooses. A) The form may be downloaded, printed, completed by hand, and mailed. B) It may be downloaded, completed on-screen, printed, signed by hand, and mailed. C) It may be downloaded, completed on-screen, and submitted on-line with a digital signature to a secure server within the Department of Labor. The form is available on the DCMWC public website at http://www.dol.gov/owcp/regs/compliance/cm-981.pdf. The URL for the form is printed on a brief cover letter that accompanies the CM-981 for use by the Registrar’s office in the event that the original form is lost or destroyed before it is returned.
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 similar approved information collection form used by the Program. The Federal Employees' Compensation Program and the Social Security Administration collect similar information but from a different beneficiary population.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
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.
If full-time student status for dependents aged 18 to 23 were verified less than yearly, there would be no dependable way to know if eligibility continues. This could create a hardship to the beneficiary because the monthly benefit check could be less than should be received, or the beneficiary could be paid too much if we incorrectly assumed full-time status. In order to determine continued eligibility, this verification must be done yearly.
7. Explain any special circumstances.
There are no special circumstances for this information collection.
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.
No outside consultants were contacted concerning the use of the CM-981. The form has been in use since 1978, and there has been ample time to voice any complaints regarding its use.
A Federal Register Notice inviting comments was published on February 22, 2013. 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 for furnishing the requested information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
The attached Privacy Act System Notice, ESA-6, provides confidentiality of information 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 a sensitive nature asked on this form.
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.
It is estimated that it takes the school's registrar about 10 minutes to retrieve the needed information, complete, mail the CM-981, and replace the records. Based on the 2012 calendar year, 493 CM-981’s were completed for a total of 82 burden hours.
10 /60 X 493 = 82
The estimated annualized cost to the respondents is $23.67 per hour (Employment and Earnings, Table B) for November 2012 by the Bureau of Labor Statistics: for the collection of this information for an approximate total of $1,940.94.
$23.67 x 82 hours = $1,940.94
Annual Costs to Respondents (capital/start-up & operation and maintenance).
There are no operation and maintenance costs to respondents.
14. Provide estimates of annualized cost to the Federal government.
The estimated total cost to the Federal Government for these 493 forms is approximately $3,643.27. The cost is figured as follows:
a. Estimated printing cost: $25.00.
b. Estimated mailing cost: $483.14 ($.46 postage plus $.03 per envelope = $.49 plus an additional $.49 = $.98 for stamps and envelopes for mailings and returns) 493 forms x $.98 = $483.14.
c. The estimated processing cost: $3,160.13 calculated at one CE (GS-12/6) (http://www.opm.gov/oca/12tables/pdf/rus_h.pdf ) spending about 10 minutes completing and evaluating the form. (The Salary Table 2012-GS was used for the hourly wages.)
$ 38.46/6 X 493 = $3,160.13
Explain the reasons for any program changes or adjustments.
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.
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.
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 ROCIS.
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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | MEMORANDUM FOR: |
| Author | Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |