Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History

Forms and Documents

Document Name	Status
Form CM-911A 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form	Modified
NOTICE TO REVIEWER.docx Justification for No Material/Nonsubstantive Change	2016-02-11
2014 Supporting Statement Revised 1240-0038 CM-911 and CM-911a (20150115).doc Supporting Statement A	2015-01-20
20CFR725.304 - Forms and initial processing.pdf Supplementary Document	2014-08-08
DOL Privacy Act systems ESA-30.pdf Supplementary Document	2014-08-08
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2014-08-08
20CFR725.404 - Development of evidence--general.docx Supplementary Document	2014-08-08

IC Document Collections

IC ID	Document Title	Status
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form	Modified

ICR Details

OMB Control No: 1240-0038	ICR Reference No: 201602-1240-004
Status: Historical Active	Previous ICR Reference No: 201405-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History
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: 04/04/2016
	Date Received in OIRA: 03/02/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	01/31/2018	01/31/2018
Responses	11,000	0	11,000
Time Burden (Hours)	7,750	0	7,750
Cost Burden (Dollars)	2,058	0	2,058

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Abstract: CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and this form is completed by all applicants, both miners and survivors.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 29218	05/21/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 63169	10/22/2014
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	CM-911A, CM-911	Employment History ,   Miner's Claim for Benefits Under the Black Lung Benefits Act

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ICR Summary 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	11,000	11,000	0	0	0	0
Annual Time Burden (Hours)	7,750	7,750	0	0	0	0
Annual Cost Burden (Dollars)	2,058	2,058	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: $210,130

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]? No

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: 03/02/2016

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