1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History

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

OMB: 1240-0038

IC ID: 13681

Information Collection (IC) Details

View Information Collection (IC)

1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.304(a) 20 CFR 725.404(a)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CM-911A Employment History cm-911a_working.pdf http://www.dol.gov/regs/compliance/owcp/cm-911a.pdf Yes No Fillable Printable
Form CM-911 Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 Feb 2016.pdf http://www.dol.gov/regs/compliance/owcp/cm-911.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

DOL/ESA-6  67 FR 16869

11,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,000 0 0 0 0 11,000
Annual IC Time Burden (Hours) 7,750 0 0 0 0 7,750
Annual IC Cost Burden (Dollars) 2,058 0 0 0 0 2,058

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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