SUPPORTING STATEMENT
Request to be Selected as Payee
1240-0010
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.
Benefits are payable by the Department of Labor to miners who are totally disabled due to pneumoconiosis and to certain survivors of a miner under the Federal Mine Safety and Health Act of 1977, as amended (30 U.S.C. 901). If a beneficiary is incapable of handling his/her affairs, the person or institution responsible for their care is required to apply to receive the benefit payments on the beneficiary's behalf. The CM‑910 is the form completed by representative payee applicants. The payee applicant completes the form and mails it for evaluation to the district office that has jurisdiction over the beneficiary's claim file. Regulations 20 CFR 725.505-513 require the collection of this information.
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.
The representative payee applicant completes the form and returns it to the district office. Upon receipt of the collected information, the claims examiner reviews the information to determine the relationship of the applicant to the beneficiary and to assess the applicant's ability to undertake the responsibilities of a representative payee.
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 form CM‑910 is available for downloading at http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm. The CM-910 can also be accessed through the Department of Labor’s on-line forms library at http://webapps.dol.gov/libraryforms/
The form can be filled out on-screen, printed, and mailed or may be printed, completed by hand, and mailed. However, it has not been made available for electronic submission. The form requires the signature of the applicant, which could be affixed electronically, but also contains a space for the signature of a witness if the applicant 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 applicant from forwarding the form to the witness after both had received their digital signature verification keys.
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.
The collection of this information does not impose a significant impact on 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 once when an institution or individual completes the application and submits it for evaluation. If this information were not collected, the Program would be unable to evaluate the applicant's ability to be a representative payee. Thus, the beneficiary's best interests would not be served, if the Program were not able to screen representative payee applicants.
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.
A Federal Register Notice inviting public comment was published on 10 December 2014 (79 FR 73340). No comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payments or gifts are made to respondents to furnish the information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
The Privacy Act Systems of Records (ESA-6 and ESA-30) provide confidentiality of information collection involving a beneficiary's records. The form contains a Privacy Act statement.
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.
There are approximately 2,300 respondents annually. One form is sent to each respondent. Approximately 15 minutes is required to complete and mail the form. Thus, there is an approximate annual burden of 575 hours (2300 X 15 = 34,500/60 = 575 hours).
It is not possible to determine the specific occupation or wages for each person who will provide the information covered by this clearance, and wages can vary considerably from person to person depending on duties and length of service, and because the respondent may not be employed at all. Therefore, we are using the national median weekly wage to estimate the annualized burden cost. This estimate is derived from use of the Median Weekly Earnings of Full-time and Salary Workers for 2014 ($790.00), as computed by the Bureau of Labor Statistics (http://www.bls.gov/news.release/wkyeng.nr0.htm). Accordingly, the calculations for the estimated annualized burden cost are as follows:
$790.00 40 hrs = $19.75/hr x 575 hrs = $ 11,356.25.
Annual Costs to Respondents (capital/start-up & operation and maintenance).
There are no technological or system costs associated with the collection of the CM-910 information. A mailing and envelope cost to the respondent of 52¢ ($.49 stamp plus $.03 envelope) is applicable as an operation cost, for a total of $1,196.00 (52¢ X 2,300 respondents).
14. Provide estimates of annualized cost to the Federal government.
The estimated total cost to the Federal Government for the 2,300 forms is $29,371.21, calculated as follows:
Estimated Printing Cost: $80.00
Estimated Mailing Cost: $1,196.00
Estimated Processing Cost: $28,095.21
Estimated total: $29,371.21
One GS‑12/4 ($36.63/hour) spends 20 minutes evaluating each of the 2,300 forms (2300 X 20 = 46,000/60 =767 hours). 767 hours x $36.63 = $28,095.21. The hourly rate is taken from Salary Table 2014GS–RUS. http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2014/RUS_h.pdf.
15. Explain the reasons for any program changes or adjustments.
There has been an enlargement of mailing cost due to postage increase and hourly rate increase for one GS-12/4 to evaluate each form.
Minor changes have been made to CM-910 to provide clearer language so applicants can better understand what information they need to provide. Finally, an accommodation statement was placed on the form to inform applicants who have mental or physical limitations to contact DCMWC if further assistance is needed in the claims process.
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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT |
| Author | US Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |