Request for State or Federal Workers' Compensation Information

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-905 Request for State or Federal Workers' Compensation Information	Form	Modified	Available
20200210 Supporting Statement 1240-0032.docx	Supporting Statement A	Uploaded 2020-02-19	Available
System of Record Notice-DOL OWCP-2.pdf	Supplementary Document	Uploaded 2019-11-14	Available
20 CFR 725 535.pdf	Supplementary Document	Uploaded 2013-06-25	Available
30 USC 924.pdf	Supplementary Document	Uploaded 2013-06-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13703	Request for State or Federal Workers' Compensation Information	Form	Modified

ICR Details

OMB Control No: 1240-0032	ICR Reference No: 201911-1240-002
Status: Historical Active	Previous ICR Reference No: 201607-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for State or Federal Workers' Compensation Information
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: 07/14/2020
	Date Received in OIRA: 02/27/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved	07/31/2020
Responses	6,000	0	2,000
Time Burden (Hours)	1,500	0	500
Cost Burden (Dollars)	3,480	0	1,000

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Abstract: DCMWC beneficiaries have their monthly benefits reduced dollar for dollar for other benefits that they receive attributable to their black lung disability from State or Federal workers' benefits. The CM-905 request the amount of those workers' compensation 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:
	84 FR 64935	11/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 11102	02/26/2020
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
Request for State or Federal Workers' Compensation Information	CM-905	Request for State or Federal Compensation Information

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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	6,000	2,000	0	0	4,000	0
Annual Time Burden (Hours)	1,500	500	0	0	1,000	0
Annual Cost Burden (Dollars)	3,480	1,000	0	0	2,480	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: Minor changes have been made to CM-905. Description of changes: Eliminated requirement for the miner’s full social security number and requiring only the last four digits, added two options to file this form (mail or electronically submit through the COAL Mine Portal), provided updated language for the Privacy Act Statement, and provided updated language for the Notice.The revisions to the form do not impact burden or respondent cost. The increase in burden due to agency estimate was a result of an estimated increase in the number of respondents.

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Annual Cost to Federal Government: $66,030

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.     No

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.     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? No

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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: 02/27/2020

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