SUPPORTING STATEMENT
Survivor's Form for Benefits
OMB No. 1240-0027(Formerly 1215-0069) (CM-912)
A. Justification
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.
This collection of information is required to administer the benefit payment provisions of the Black Lung Benefits Act for survivors of deceased miners. Completion of this form constitutes the application for benefits by survivors and assists in determining the survivor's entitlement to benefits. This form is authorized by the Black Lung Benefits Act (30 USC 901, et seq.) and by 20 CFR 410.221 and 20 CFR 725.304.
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.
Survivor applications are used by Division of Coal Mine Workers' Compensation (DCMWC) claims examiners to determine a survivor's eligibility for benefits. The claims examiners review the information submitted with the survivor's application along with any pertinent evidence already in file and, as necessary, informs the claimant of any additional information needed to meet the eligibility requirements to adjudicate the claim. The eligibility requirements are given in 20 CFR 725.212-225.
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 is available for downloading at http://www.dol.gov/owcp/regs/compliance/cm-912.pdf. It can be filled out on-screen, printed, and mailed, or it may be printed, completed by hand, and mailed. It has not been made available for electronic submission previously because it contained a space for the signature of a witness if the claimant is unable to sign his or her name. Electronic signature would have required two digital signature verification keys, a process unsupported by the Department of Labor’s software. However, virtually no forms with witness signatures are now submitted, and DCMWC intends to make the form fileable on-line in the near future.
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 A.2 above.
There is no similar approved form used by DCMWC. Since the information collected is specific to Federal Black Lung beneficiary survivors, no other agency gathers this information.
If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
Collection of this information does not involve small businesses or other small entities.
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 is a one-time collection from applicants; if the collection were less frequent, survivors eligible for benefits under the Black Lung Benefits Act would not be able to exercise their right to apply.
Explain any special circumstances required in the conduct of this information collection.
There are no special circumstances for conducting this information collection.
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 anytime a question or problem is raised.
A Federal Register Notice inviting public comment was published on June 14, 2013 [78FR35982]. No comments were received.
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.
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
Privacy Act System Notices (ESA-6 and ESA-30) provide confidentiality of information collected involving a claimant's claim file and automated 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.
There are no questions of a sensitive nature on this form.
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.
The burden estimate for the CM-912 is based upon the approximately 1,100 forms received yearly by DCMWC district offices. A survivor needs to fill out an application only once. It takes approximately 8 minutes per response, for a total annual burden of 147 hours.
(1,100 forms x 8 min= 8,800 min/60 = 147 hours)
Annual Costs to Respondents (capital/start-up & operation and maintenance).
The estimated total cost to respondents for the burden hours is approximately $626.22. The cost is computed by using the hourly Black Lung beneficiary benefit rate of $4.26. ($625 monthly x 12 = $7,500 a year/220 OPM annual workdays = $34.09/8 work hours a day = $4.26 hourly. $4.26 x 147 work hours = $626.22)
Operation and maintenance costs consist of mailing costs for the form. Approximately 200 of the forms are completed at Black Lung offices and thus incur no mailing costs. About 900 of the completed responses are mailed to the Black Lung offices at a cost of $.49 ($.46 postage and .03 for the envelope), for a total of $441.00. ($.49 x 900 = $441.00)
Provide estimates of annualized cost to the Federal government.
The estimated total cost to the Federal government for this information collection is approximately $12,552.00. The cost is computed as follows:
a. Estimated printing cost: $300.00
b. Estimated mailing cost: $441.00
(Stamps and envelopes @ $.49 for 900 forms sent to the claimant for completion, this excludes the approximate 200 forms completed by a Black Lung office)
c. Estimated processing cost: $9,000.75
(Claims Examiner, GS-12/5, spends about 15 minutes evaluating each form: $32.73 x 1,100/4 = $9,000.75
d. Estimated SSA contract costs: $2,810.25
(SSA is under contract with DCMWC for claim taking services at SSA district offices throughout the country. The price per claim intake is $37.47. Of the 200 responses taken at DCMWC or SSA offices, it is estimated that approximately 75 will be taken by SSA. (75 x $37.47 = $2,810.25)
Explain the reasons for any program changes or adjustments.
There is a decrease in the approximate number of respondents from 1,750 to 1,100, due to the mortality rate of an aging claimant population. The total number of burden hours has decreased by 650 hours.
BURDEN HOURS RESPONSES
Current inventory 233 1,750
Requested 147 1,100
Difference -86 -650
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.
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.
Explain each exception to the certification in ROCIS.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods.
There are no exceptions to the certification statement.
| File Type | application/msword |
| Author | US Department of Labor |
| Last Modified By | yferguso |
| File Modified | 2013-09-25 |
| File Created | 2013-09-25 |