Request for State or Federal Workers' Compensation Information

ICR 201911-1240-002

OMB: 1240-0032

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2020-02-19
Supplementary Document
2019-11-14
Supplementary Document
2013-06-25
Supplementary Document
2013-06-25
IC Document Collections
ICR Details
1240-0032 201911-1240-002
Historical Active 201607-1240-002
DOL/OWCP
Request for State or Federal Workers' Compensation Information
Revision of a currently approved collection   No
Regular
Approved without change 07/14/2020
Retrieve Notice of Action (NOA) 02/27/2020
  Inventory as of this Action Requested Previously Approved
07/31/2023 36 Months From Approved 07/31/2020
6,000 0 2,000
1,500 0 500
3,480 0 1,000

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.

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

Not associated with rulemaking

  84 FR 64935 11/25/2019
85 FR 11102 02/26/2020
No

1
IC Title Form No. Form Name
Request for State or Federal Workers' Compensation Information CM-905 Request for State or Federal Compensation 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 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
No
No
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.

$66,030
No
    No
    No
No
No
No
No
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.
02/27/2020


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