Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-787 Physician's Medical Officer's Statement	Form and Instruction	Removed	Available
Form CM-623 Representative Payee Report	Form and Instruction	Removed	Available
Form CM-787 Physician's/Medical Officer's Statement	Form and Instruction	Modified	Repair queued
Form CM-623S Representative Payee Report (Short Form)	Form and Instruction	Modified	Available
Form CM-623 Representative Payee Report	Form and Instruction	Modified	Repair queued
725.513.docx	Supplementary Document	Uploaded 2017-12-06	Available
725.511.docx	Supplementary Document	Uploaded 2017-12-06	Available
System of Record Notice.pdf	Supplementary Document	Uploaded 2017-12-06	Available
1240-0020 Supporting Statement 2018.docx	Supporting Statement A	Uploaded 2018-01-18	Available
725.506 - 510.pdf	Supplementary Document	Uploaded 2014-08-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
185863	Representative Payee Report and Physician's/Medical Officer's Statement	Form and Instruction	Removed	Physician's Medical Officer's Statement
185863	Representative Payee Report and Physician's/Medical Officer's Statement	Form and Instruction	Removed	Representative Payee Report
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form and Instruction	Modified	Physician's/Medical Officer's Statement
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form and Instruction	Modified	Representative Payee Report (Short Form)
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form and Instruction	Modified	Representative Payee Report

ICR Details

OMB Control No: 1240-0020	ICR Reference No: 201710-1240-001
Status: Historical Active	Previous ICR Reference No: 201405-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/06/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/01/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	36 Months From Approved	04/30/2018
Responses	1,325	0	2,100
Time Burden (Hours)	679	0	1,642
Cost Burden (Dollars)	0	0	0

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Abstract: Representative Payee Report (CM-623) and Representative Payee Report Short Form (CM-623S) are used to ensure that benefits paid to a representative payee are being used for the beneficiary's well-being. Physician's/Medical Officer's Statement (CM-787) is used to determine the beneficiary's capability to manage monthly Black Lung benefits.

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Authorizing Statute(s): US Code: 30 USC 922 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:
	82 FR 47772	10/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 5695	02/01/2018
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Representative Payee Report and Physician's/Medical Officer's Statement	CM-787, CM-623	Representative Payee Report ,   Physician's Medical Officer's Statement
Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	CM-623, CM-623S, CM-787	Representative Payee Report ,   Representative Payee Report (Short Form) ,   Physician's/Medical Officer's Statement

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ICR Summary of Burden

table that charts list 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	1,325	2,100	0	-775	0	0
Annual Time Burden (Hours)	679	1,642	0	-963	0	0
Annual Cost Burden (Dollars)	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total decrease in the total burden hours for all three forms is 963 hours, with the current total burden hours being 679. The prior total burden hours for all three forms were 1,642. Form CM-623 decreased by 900 hours, with a current burden of 450 hours. The CM-623S increased by 37 hours, with a current burden of 54 hours. The CM-787 decreased by 100 hours, with a current burden of 175 hours. The total decrease in the total burden hours for all three forms is 963 hours. The CM-623 and CM-623S are no longer used as the annual accounting of a beneficiary’s benefits, but rather are just used for the final accounting of a beneficiary’s benefits, due to death or due to a change in representative payee appointment. The number of burden hours for form CM-787 has decreased due to fewer determinations of incapability or incompetence medical opinions needed.

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Annual Cost to Federal Government: $13,857

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 02/01/2018

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