Claim Adjudication Process for Alleged Presence of Pneumoconiosis

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-988 Medical History and Examination	Form	Modified	Available
Form CM-2907 Report of Ventilatory Study	Form	Modified	Available
Form CM-1159 Report of Arterial Blood Gas Test	Form	Modified	Available
Form CM-933 Radiologic Interpretation	Form	Modified	Available
Form CM-933b Radiologic Quality Rereading	Form	Modified	Available
Notice To Reviewer.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-05-14	Available
2013_1240-0023_CM-988,CM_933,_CM-933b,_CM-2907,_CM-1159(Final).docx	Supporting Statement A	Uploaded 2013-11-19	Available
1240-0023 20CFR718.101 - 105.pdf	Supplementary Document	Uploaded 2011-05-27	Available
DOL Privacy Act systems ESA-30.pdf	Supplementary Document	Uploaded 2008-02-10	Available
DOL Privacy Act systems ESA-6.pdf	Supplementary Document	Uploaded 2008-02-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13765	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified	Medical History and Examination
13765	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified	Report of Ventilatory Study
13765	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified	Report of Arterial Blood Gas Test
13765	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified	Radiologic Interpretation
13765	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified	Radiologic Quality Rereading

ICR Details

OMB Control No: 1240-0023	ICR Reference No: 201412-1240-015
Status: Historical Active	Previous ICR Reference No: 201405-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim Adjudication Process for Alleged Presence of Pneumoconiosis
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: 06/17/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/14/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	36 Months From Approved	05/31/2017
Responses	24,000	0	24,000
Time Burden (Hours)	5,840	0	5,840
Cost Burden (Dollars)	0	0	0

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Abstract: 20 CFR 718 specifies that certain information relative to the medical condition of a claimant who is alleging the presence of pneumoconiosis be obtained as a routine function of the claim adjudication process. The medical specifications in the regulations have been formatted in a variety of forms to promote efficiency and accuracy in gathering the required data. These forms were designed to meet the need to gather medical evidence.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Federal Coal Mine Health & Safety Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1240-AA07	Not associated with rulemaking	79 FR 21606	04/17/2014

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Federal Register Notices & Comments
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69449	11/19/2013
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	CM-1159, CM-2907, CM-933b, CM-933, CM-988	Radiologic Quality Rereading ,   Radiologic Interpretation ,   Report of Arterial Blood Gas Test ,   Report of Ventilatory Study ,   Medical History and Examination

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ICR Summary of Burden

table that charts list 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	24,000	24,000	0	0	0	0
Annual Time Burden (Hours)	5,840	5,840	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: $2,883,212

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]? Yes

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: 05/14/2015

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