Representative Payee Report, Representative Payee Report Short Form, and Physician's/Medical Officer's Statement

Forms and Documents

Document Name	Status
Form CM-623 Representative Payee Report and Physician's/Medical Officer's Statement Form and Instruction	Modified
Form CM-623 Representative Payee Report, Representative Payee Report, Short Form, and Physician's/Medical Officer's Statement Form and Instruction	Modified
2014 1240-0020 SUPPORTING STATEMENT CM-623 CM-623S CM-787.docx Supporting Statement A	2014-10-06
DOL Privacy Act systems ESA-30.pdf Supplementary Document	2014-08-01
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2014-08-01
725.506 - 510.pdf Supplementary Document	2014-08-01

IC Document Collections

IC ID	Document Title	Status
185863	Representative Payee Report and Physician's/Medical Officer's Statement Form and Instruction	Modified
13881	Representative Payee Report, Representative Payee Report, Short Form, and Physician's/Medical Officer's Statement Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0020	ICR Reference No: 201405-1240-004
Status: Historical Active	Previous ICR Reference No: 201107-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Representative Payee Report, Representative Payee Report Short Form, and Physician's/Medical Officer's Statement
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: 01/02/2015
	Date Received in OIRA: 10/14/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved	01/31/2015
Responses	2,100	0	2,100
Time Burden (Hours)	1,642	0	1,642
Cost Burden (Dollars)	0	0	0

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Abstract: Representative Payee Report (CM-623) and Representative Payee Report Short Form (CM-623S) are used to ensure that benefits paid to a representative payee are being used for the beneficiary's well-being. Physician's/Medical Officer's Statement (CM-787) is used to determine the beneficiary's capability to manage monthly Black Lung benefits.

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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:
	79 FR 29219	05/21/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 61655	10/14/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Representative Payee Report, Representative Payee Report, Short Form, and Physician's/Medical Officer's Statement	CM-623, CM-623S, CM-787	Representative Payee Report ,   Representative Payee Report (Short Form) ,   Physician's/Medical Officer's Statement
Representative Payee Report and Physician's/Medical Officer's Statement	CM-787, CM-623	Representative Payee Report ,   Physician's Medical Officer's Statement

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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	2,100	2,100	0	0	0	0
Annual Time Burden (Hours)	1,642	1,642	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: $29,883

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: 10/14/2014

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