Esa 6

DOL Privacy Act systems ESA-6.pdf

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

ESA 6

OMB: 1240-0020

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Federal Register / Vol. 67, No. 67 / Monday, April 8, 2002 / Notices

16869

medical records contained in these files
may adversely affect the health of
individuals without guidance of a
responsible physician.

SAFEGUARDS:

CATEGORIES OF RECORDS IN THE SYSTEM:

Files located in restricted area of a
Federal building under guard by
security officers.

DOL/ESA–5

RETENTION AND DISPOSAL:

SYSTEM NAME:

Files are destroyed 10 years after case
is closed.

Personal (name, date of birth, social
security number, claim type, miner’s
date of death), medical, and financial.
Information gathered in connection with
investigations concerning possible
violations of Federal law, whether civil
or criminal, under the authorizing
legislation and related Acts. This record
also contains investigative records and
the work product of the Department of
Labor and other governmental personnel
and consultants involved in the
investigations. If the individual has
received benefits to which he or she is
not entitled, the system may contain
consumer credit reports correspondence
to and from the debtor, information or
records relating to the debtor’s current
whereabouts, assets, liabilities, income
and expenses, debtor’s personal
financial statements, and other
information such as the nature, amount
and history of a claim filed by an
individual covered by this system, and
other records and reports relating to the
implementation of the Debt Collection
Act of 1982 including any investigative
records or administrative review
matters. The individual records listed
herein are included only as pertinent to
the individual claimant.

Office of Workers’ Compensation
Programs, Black Lung
Antidiscrimination Files.

SYSTEM MANAGER(S) AND ADDRESS:

Director, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, 200 Constitution
Avenue, NW, Washington, DC 20210.

SECURITY CLASSIFICATION:

None.
SYSTEM LOCATION:

Office of Workers’ Compensation
Programs, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, 200 Constitution
Avenue, NW, Washington, DC 20210.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

Individuals filing complaints against
employers on account of discharge or
other acts of discrimination by reason of
pneumoconiosis disease.
CATEGORIES OF RECORDS IN THE SYSTEM:

Individual correspondence,
investigative records, employment
records, payroll records, medical
reports, any other documents or reports
pertaining to an individual’s work
history, education, medical condition or
hiring practices of the employer.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

30 U.S.C. 938.
To maintain records that are used to
process complaints against employers
who discharge or otherwise
discriminate against individuals
because they suffer from
pneumoconiosis disease.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:

Disclosure of file content may be
made to any party in interest to the
complaint, including the coal company,
the claimant, medical providers, and
legal representatives of any party for
purposes related to the complaint.
DISCLOSURE TO CONSUMER REPORTING
AGENCIES:

Not applicable.
POLICIES AND PRACTICES FOR STORING,
RETRIEVING, ACCESSING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:

RECORD ACCESS PROCEDURES:

Individuals wishing to request access
to their records should contact the
system manager at the above address.
Individuals must furnish their name,
address and signature.
CONTESTING RECORD PROCEDURES:

Individuals wishing to request
amendment of any record should
contact the system manager at the above
address. Individuals must furnish their
name, address and signature.
RECORD SOURCE CATEGORIES:

Manual files.
RETRIEVABILITY:

Coal miner’s name and social security
number.

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SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS
OF THE ACT:

Not applicable.
DOL/ESA–6
SYSTEM NAME: OFFICE OF WORKERS’
COMPENSATION, BLACK LUNG

Benefits Claim File.
SECURITY CLASSIFICATION:

SYSTEM LOCATION:

Office of Workers’ Compensation
Programs, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, 200 Constitution
Avenue, NW, Washington, DC 20210,
and district offices (see addresses in the
Appendix to this document).

Individuals filing claims for black
lung (pneumoconiosis) benefits under
the provisions of Black Lung Benefits
Act, as amended, including miners, and
their surviving spouses, children,
dependent parents and siblings.

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AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

30 U.S.C. 901 et seq., 20 CFR 715.1 et
seq., 20 CFR 720.1 et seq., 20 CFR 725.1
et seq.
PURPOSE(S):

To maintain records that are used to
process all aspects of claims for black
lung (pneumoconiosis) benefits under
the provisions of the Black Lung
Benefits Act, as amended, including
claims filed by miners and their
surviving spouses, children, dependent
parents and siblings. These records are
also used to process the recoupment of
overpayments under the Act.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:

Unclassified.

CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

STORAGE:

19:00 Apr 05, 2002

Individuals wishing to inquire
whether this system of records contains
information about them should contact
the system manager at the above
address. Individuals must furnish their
name, address and signature.

Individuals, employers, medical
providers and investigators.

PURPOSE(S):

VerDate 112000

NOTIFICATION PROCEDURE:

In addition to those universal routine
uses listed in the General Prefatory
Statement of this document, disclosure
of relevant and necessary information
may be made to the following:
a. Mine operators (and/or any party
providing the operator with benefits
insurance) who have been determined
potentially liable for the claim at any
time after the filing of a claim for Black
Lung Benefits for the purpose of
determining liability for payment.
b. State workers’ compensation
agencies and the Social Security
Administration for the purpose of
determining offsets as specified under
the Act.

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Federal Register / Vol. 67, No. 67 / Monday, April 8, 2002 / Notices

c. Doctors and medical services
providers for the purpose of obtaining
medical evaluations, physical
rehabilitation or other services.
d. Representatives of the claimant for
the purpose of processing the claim,
responsible operator and program
representation on contested issues.
e. Labor unions and other voluntary
employee associations of which the
claimant is a member for the purpose of
assisting the member.
f. Contractors providing automated
data processing services to the
Department of Labor, or to any agency
or entity to whom release is authorized,
where the contractor is providing a
service relating to the purpose for which
the information can be released.
g. Federal, state or local agencies if
necessary to obtain information relevant
to a Departmental decision concerning
the determination of initial or
continuing eligibility for program
benefits, including whether benefits
have been or are being paid improperly;
whether dual benefits prohibited under
any federal or state law are being paid;
and including salary offset and debt
collection procedures, including any
action required by the Debt Collection
Act of 1982.
h. Debt collection agency that DOL
has contracted for collection services to
recover indebtedness owed to the
United States.
i. Internal Revenue Service for the
purpose of obtaining taxpayer mailing
addresses in order to locate such
taxpayers to collect, compromise, or
write-off a Federal claim against the
taxpayer; discharging an indebtedness
owed by an individual.
j. Credit Bureaus for the purpose of
receiving consumer credit reports
identifying the assets, liabilities, income
and expenses of a debtor to ascertain the
debtor’s ability to pay a debt and to
establish a payment schedule.
Note: Disclosure to a claimant or a person
who is duly authorized to act on the
claimant’s or beneficiary’s behalf, of
information contained in the file may be
made over the telephone. Disclosure over the
telephone will only be done where the
requestor provides appropriate identifying
information to OWCP personnel. Telephonic
disclosure of information is essential to allow
OWCP to efficiently perform its functions in
adjudicating and servicing claims.
DISCLOSURE TO CONSUMER REPORTING
AGENCIES:

The amount, status and history of
overdue debts; the name and address,
taxpayer identification (SSAN), and
other information necessary to establish
the identity of a debtor, the agency and
program under which the claim arose,
are disclosed pursuant to 5 U.S.C.

VerDate 112000

19:00 Apr 05, 2002

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552a(b)(12) to consumer reporting
agencies as defined by the Fair Credit
Reporting Act (15 U.S.C. 1681a(f), or in
accordance with the Federal Claims
Collection Act of 1966 as amended (31
U.S.C. 3711(e) for the purpose of
encouraging the repayment of an
overdue debt.
POLICIES AND PRACTICES FOR STORING,
RETRIEVING, ACCESSING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:

Case file documents, both original and
copies, in manual files.
RETRIEVABILITY:

Coal miner’s name, social security
number, and claimant’s social security
number different from miner’s.
SAFEGUARDS:

Files are located in the restricted area
of a Federal building under guard by
security officers.
RETENTION AND DISPOSAL:

Approved claims files are destroyed
10 years after death of last beneficiary.
Denied claims are destroyed 30 years
after final denial.
SYSTEM MANAGER(S) AND ADDRESS:

Director, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, Room C–3520, 200
Constitution Avenue, NW, Washington,
DC 20210, and district office directors
(see addresses in the Appendix to this
document).
NOTIFICATION PROCEDURE:

Individuals wishing to inquire
whether this system of records contains
information about them should contact
the system manager at the above
address, or district office directors. (See
addresses in the Appendix to this
document.) Individuals must furnish
claimant’s name, and signature.
RECORD ACCESS PROCEDURE:

Individuals wishing to request access
to non-exempt records should contact
the appropriate office listed in the
Notification Procedure section. The
individual must furnish his or her
name, signature and address.
CONTESTING RECORD PROCEDURES:

Specific materials in this system have
been exempted from Privacy Act
provisions (5 U.S.C. 552a(d)), regarding
access to records. The section of this
notice titled ‘‘Systems Exempted from
Certain Provisions of the Act’’ indicates
the kinds of materials exempted from
access and the reasons for exempting
them from access. Individuals wishing
to request amendment of any non-

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exempt records should contact the
appropriate office listed in the
Notification Procedure section.
Individuals must furnish their name,
address and signature.
RECORD SOURCE CATEGORIES:

Individuals, organizations, and
investigators.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS
OF THE ACT:

In accordance with 5 U.S.C.
552a(k)(2), investigatory material in this
system of records compiled for law
enforcement purposes is exempt from
subsections (c)(3); (d); (e)(1); (e)(4)(G),
(H), and (I); and (f) of 5 U.S.C. 552a,
provided however, that if any
individual is denied any right, privilege,
or benefit that he or she would
otherwise be entitled to by Federal law,
or for which he or she would otherwise
be eligible, as a result of the
maintenance of these records, such
material shall be provided to the
individual, except to the extent that the
disclosure of such material would reveal
the identity of a source who furnished
information to the Government under an
express promise that the identity of the
source would be held in confidence, or
prior to January 1, 1975, under an
implied promise that the identity of the
source would be held in confidence.
DOL/ESA–15
SYSTEM NAME:

Office of Workers’ Compensation
Programs, Longshore and Harbor
Workers’ Compensation Act Case Files.
SECURITY CLASSIFICATION:

None.
SYSTEM LOCATION:

Division of Longshore and Harbor
Workers’ Compensation, Office of
Workers’ Compensation Programs,
Washington, DC 20210, and district
offices of the Office of Workers’
Compensation Programs set forth in the
Appendix to this document.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

Employees injured or killed while
working in private industry who are
covered by the provisions of the
Longshore and Harbor Workers’
Compensation Act, the NonAppropriated Fund Instrumentalities
Act, the Defense Base Act, the War
Hazards Act, and the DC Workers’
Compensation Act, referred to
collectively herein as the Longshore and
Harbor Workers’ Compensation Act
(LHWCA).

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File Typeapplication/pdf
File TitleDocument
SubjectExtracted Pages
AuthorU.S. Government Printing Office
File Modified2005-02-06
File Created2005-02-06

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