Authorization for Release of Medical Information for Black Lung Benefits

ICR 201602-1240-006

OMB: 1240-0034

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Justification for No Material/Nonsubstantive Change
2016-03-14
Supporting Statement A
2015-08-12
Supplementary Document
2006-08-09
Supplementary Document
2006-08-09
Supplementary Document
2006-08-09
Supplementary Document
2006-08-09
Supplementary Document
2006-08-09
Supplementary Document
2006-08-09
IC Document Collections
IC ID
Document
Title
Status
13694 Modified
ICR Details
1240-0034 201602-1240-006
Historical Active 201505-1240-002
DOL/OWCP
Authorization for Release of Medical Information for Black Lung Benefits
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/04/2016
Retrieve Notice of Action (NOA) 03/14/2016
  Inventory as of this Action Requested Previously Approved
11/30/2018 11/30/2018 11/30/2018
900 0 900
75 0 75
0 0 0

The CM-936 is used to obtain the black lung claimant's authorization for the Division of Coal Mine Workers' Compensation to request medical evidence in support of the black lung claim.

US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  80 FR 28302 05/18/2015
80 FR 50045 08/18/2015
No

1
IC Title Form No. Form Name
Authorization for Release of Medical Information CM-936 Authorization For Release of Medical Information

  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 900 900 0 0 0 0
Annual Time Burden (Hours) 75 75 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$3,835
No
No
No
No
No
Uncollected
Debbie Thurston 202 693-0913 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/14/2016


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