Survivor's Form for Benefits Under the Black Lung Benefits Act

Forms and Documents

Document Name	Status
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form	Modified
SS 1240-0027 CM-912 2016.doc Supporting Statement A	2016-12-21
DOL Privacy Act Systems ESA-6.pdf Supplementary Document	2013-06-25
DOL Privacy Act Systems ESA-30.pdf Supplementary Document	2013-06-25

IC Document Collections

IC ID	Document Title	Status
13721	Survivor's Form for Benefits Under the Black Lung Benefits Act Form	Modified

ICR Details

OMB Control No: 1240-0027	ICR Reference No: 201607-1240-001
Status: Historical Active	Previous ICR Reference No: 201510-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Survivor's Form for Benefits Under the Black Lung Benefits Act
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/02/2017
	Date Received in OIRA: 12/28/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	1,100	0	1,100
Time Burden (Hours)	147	0	147
Cost Burden (Dollars)	450	0	441

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Abstract: The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

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:
	81 FR 49270	07/27/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 95650	12/28/2016
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
Survivor's Form for Benefits Under the Black Lung Benefits Act	CM-912	Survivor's Form 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	1,100	1,100	0	0	0	0
Annual Time Burden (Hours)	147	147	0	0	0	0
Annual Cost Burden (Dollars)	450	441	0	0	9	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: $13,864

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: 12/28/2016

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