Report of Changes That May Affect Your Black Lung Benefits

Forms and Documents

Document Name	Status
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits Form and Instruction	Modified
Notice To Reviewer July 2013.docx Justification for No Material/Nonsubstantive Change	2013-07-01
Attachment 1-Notice to Reviewer CM-929 and CM-929P.docx Justification for No Material/Nonsubstantive Change	2012-08-08
Supporting Statement 1240-0028 (CM-929 and 929P).doc Supporting Statement A	2011-07-27
30 USC Sec_ 936 (1993).htm Supplementary Document	2008-03-12
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2008-03-12

IC Document Collections

IC ID	Document Title	Status
13756	Report of Changes That May Affect Your Black Lung Benefits Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0028	ICR Reference No: 201306-1240-007
Status: Historical Active	Previous ICR Reference No: 201207-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Report of Changes That May Affect Your Black Lung Benefits
Type of Information Collection: No material or nonsubstantive change to 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: 07/10/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	09/30/2014	09/30/2014
Responses	55,000	0	55,000
Time Burden (Hours)	12,627	0	12,627
Cost Burden (Dollars)	0	0	0

---

Abstract: This information collection is necessary to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Disability Trust Fund. It is also necessary to verify and update on a regular basis factors that affect a beneficiary's entitlement to benefits, including income, marital status, receipt of State Worker's Compensation, and dependent status.

---

Authorizing Statute(s): US Code: 30 USC 936 Name of Law: Federal Mine Safety and Health Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 13669	03/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 35914	06/20/2011
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Report of Changes That May Affect Your Black Lung Benefits	CM-929, CM-929P	Report of Changes That May Affect Your Black Lung Benefits ,   Report of Changes That May Affect Your Black Lung Benefits

---

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	55,000	55,000	0	0	0	0
Annual Time Burden (Hours)	12,627	12,627	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: The total burden hours have decreased by 2,642 hours, from 15,269 to 12,627. This adjustment reflects a declining population of both Part C and Part B beneficiaries.

---

Annual Cost to Federal Government: $366,382

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

---

Common Form ICR:  No

---

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: 07/10/2013

---