SUPPORTING STATEMENT
Miner's Claim for Benefits under the Black Lung Benefits Act and Employment History
1240-0038
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.
CM‑911
Title IV of the Federal Mine Safety and Health Act of 1977 as amended by the Black Lung Benefits Reform Act of 1977 and subsequent amendments, 30 USC 901 et seq., provides for the payment of benefits to a coal miner who is totally disabled due to pneumoconiosis (black lung disease) and to certain survivors of the miner who died due to pneumoconiosis.
A miner who applies for black lung benefits must complete the CM‑911 (application form). The completed form gives basic identifying information about the applicant and is the beginning of the development of the black lung claim. The Black Lung Benefits Act as amended, 30 USC 901 et seq., and 20 CFR 725.304a, necessitates the collection of this information.
CM‑911a
An applicant filing for black lung benefits must complete a CM‑911a at the same time the black lung application form is submitted. This form when completed is formatted to render a complete history of employment and helps to establish if the miner currently or formerly worked in the nation's coal mines. The person filing for benefits must have worked in the nation's coal mines or be a survivor of a coal miner as described under Title IV of the Federal Mine Safety and Health Act of 1977, as amended, in order for benefits to be pursued. The Black Lung Benefits Act, as amended and 20 CFR 725.404(a) necessitates the collection of this information.
The collection of the coal miner’s Social Security number is necessary because of offset provisions in the laws for both the Social Security Administration and Black Lung in order to prevent overpayments and duplicate benefits. DCMWC masks the SSN on all outgoing correspondence so that all digits except the last four appear as X.
The SSN is also needed to coordinate medical treatment benefits between the Black Lung Program and other health care insurers to prevent duplicate reimbursement. Also, the universal billing form (CMS-1500) and our version (OWCP-1500) use the SSN, it would be almost impossible to properly pay medical providers for the treatment service given to disabled miners without it.
2. 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.
CM‑911
Upon completion by the applicant and receipt of the CM‑911 by the Black Lung District Office, the claims examiner (CE) reviews the information and begins the verification process of each item on the application. For example, the CE requests certified copies of the birth and marriage records to establish dependency and to help determine the potential amount of benefits to which the miner would be entitled. Upon receipt and verification of all items requested, the CE can determine if the applicant meets the statutory criteria for an award of benefits. If this information were not collected and the miner's signature were not obtained on the CM‑911, the requirements of the Black Lung Benefits Act would not be met.
CM‑911a
Once the CM‑911a is completed and received in the black lung office, the CE reviews and verifies the information to determine if coal mine employment is established. Other types of employment are also reviewed to help establish total disability due to coal mine employment. Proof of coal mine employment is a major element in establishing a causal relationship between employment and total disability due to pneumoconiosis for entitlement purposes. If this information were not gathered, neither coal mine employment nor the length of that employment could be established.
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 forms can be filled out on-screen, printed, and mailed or may be printed, completed by hand, and mailed. However, they have not been made available for electronic submission. Each form requires the signature of the claimant, which could be affixed electronically, but also contains a space for the signature of a witness if the claimant is unable to sign his or her name. Two independently-obtained digital signatures by different people would be required to submit such a form on-line and, in order to keep claim information confidential, the Department of Labor’s website does not permit forwarding or submission of on-line forms to any place other than the Department’s designated electronic mailbox. This would prevent the claimant from forwarding the form to the witness after both had received their digital signature verification keys.
These forms are available for downloading at: http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm.
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 information available.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
Collection of this information 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.
This information is collected only at the time of application. If it were collected less frequently, this information would not be available for case adjudication.
7. Explain any special circumstance required in the conduct of this information collection.
There are no special circumstances for this information collection.
8. 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.
Consultations with respondents take place at any time a question or problem is raised.
A Federal Register Notice inviting public comment was published on 21 May 2014 (76FR29218). 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 any gifts or payments to furnish the requested information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
Privacy Act System Notice ESA‑6 provides for confidentiality of information collection involving a claimant's record.
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.
This collection contains no questions of a sensitive nature.
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.
CM‑911
The estimated burden of this information collection is approximately 3,750 hours. This burden is based on a submission of 5,000 CM‑911's with 45 minutes to read and complete the form. The local Social Security Office or Black Lung Office supplies the form and helps the claimant complete the form.
45 minutes x 5,000 forms = 3,750 total burden hours.
For the burden cost to the applicant, we use the minimum wage of $7.25 per hour.
3,750 burden hours x $7.25 per hour = $27,187.50
CM‑911a
The estimated burden of this information collection is approximately 4,000 hours. This burden is based on a submission of 6,000 CM‑911a's with 40 minutes to read and complete the form. The local Social Security Office or Black Lung Office supplies the form and helps the claimant complete the form.
40 minutes x 6,000 forms = 4,000 total burden hours.
For the burden cost to the applicant, we use the minimum wage of $7.25 per hour.
4,000 burden hours x $7.25 per hour = $29,000.
Annual Costs to Respondents (capital/start-up & operation and maintenance).
Since the CM-911 and the CM-911a are generally completed and returned at the same time, no additional mailing costs appear for the CM-911. An estimated 70% (4,200) of the respondents mail their response, and the cost is estimated at 49 cents per respondent for postage and envelope. The estimated cost for operations and maintenance has increased from $1,771.00 to $2,058.00 due to the increased number of respondents. The total respondent cost is $2,058.00. The cost is figured as follows:
CM-911: no cost
CM-911a: 4,200 x .49 = $2,058.00
14. Provide estimates of annualized cost to the Federal government.
CM‑911
The estimated total cost to the Federal Government for 5,000 CM‑911's is approximately $95,000.00.
a. Estimated printing cost: $650.00
b. Estimated mailing cost: None - Forms obtained from Black Lung or Social Security District Office.
c. Estimated processing cost: $94,350.00
GS‑12/5 spends about 30 minutes per form for review
$37.74 x .50 x 5,000 = $94,350.00 (GS-12/5 RUS salary from http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2014/RUS_h.pdf
CM‑911a
The estimated total cost to the Federal government for 6,000 CM‑911a's is approximately $115,130.00.
a. Estimated printing cost: $350.00
b. Estimated mailing cost: $1,560.00
Since the CM-911 and the CM-911a are mailed at the same time, no additional mailing costs appear for the CM-911. An estimated 50% (3,000) of the CM-911 and CM-911a are sent to the black lung applicants, and the cost is estimated at 52 cents per applicant for postage and envelope. The total mailing cost is $1,560.00. The cost is figured as follows:
CM-911: no cost
c. Estimated processing cost: $113,220.00
GS‑12/5 spends about 30 minutes per form for review
$37.74 x .50 x 6,000 = $113,220.00
15. Explain the reasons for any program changes or adjustments.
There has been an increase for the Federal cost due to a postage rate increase.
Additionally, the annual number of responses rose by 1,500 from 5,500 to 11,000. These increases are the result of coal mine closures and outreach efforts. When a coal mine closes, OWCP receives more black lung benefits applications. OWCP district offices also increased their outreach efforts which, in turn, resulted in an increase in black lung benefits applications.
While not expected to affect respondent burden, this ICR has been classified as a revision because of minor changes to the forms. The changes clarify certain sections so claimants can better understand what information to provide. The OWCP has also incorporated a notice that informs persons with disabilities how they may request assistance to complete the information collection.
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.
17. 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 ICR 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.
Collections of Information Employing Statistical Methods.
Statistical methods are not used in these collections of information.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | US Department of Labor |
| Last Modified By | Ferguson, Yoon - OWCP |
| File Modified | 2015-01-15 |
| File Created | 2015-01-15 |