Survivor’s form for Benefits under the Black Lung Benefits Act
1240-0027 (CM-912)
March 2020
SUPPORTING STATEMENT
Survivor's Form for Benefits Under The Black Lung Benefits Act
1240-0027
A. Justification
Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.
This collection of information is required to administer the benefit payment provisions of the Black Lung Benefits Act for survivors of deceased miners. Completion of this form constitutes the application for benefits by survivors and assists in determining the survivor's entitlement to benefits. This form is authorized by the Black Lung Benefits Act (30 USC 901-945) and its implementing regulations (20 CFR 725.304).
Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
Survivor applications are used by Division of Coal Mine Workers' Compensation (DCMWC) claims staff to determine a survivor's eligibility for benefits. The claims staff reviews the information submitted with the survivor's application along with any pertinent evidence already in file and, as necessary, informs the claimant of any additional information needed to meet the eligibility requirements to adjudicate the claim. The eligibility requirements are given in 20 CFR 725.212-225.
Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
The form is available for downloading at http://www.dol.gov/owcp/regs/compliance/cm-912.pdf. It can be filled out on-screen, printed, signed, and mailed, or it may be printed, completed by hand, signed, and mailed. The completed form cannot be submitted online through the COAL Mine Portal because the user must have a Case ID# first before being able to utilize the portal. It has not been made available for electronic submission with digital signatures since electronic signatures would require two digital signature verification keys, a process unsupported by the Department of Labor’s software. No forms have been received electronically.
Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.
There is no similar approved form used by DCMWC. Since the information collected is specific to Federal Black Lung beneficiary survivors, no other agency gathers this information.
If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
Collection of this information does not involve small businesses or other small entities.
Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
This is a one-time collection from applicants; if the collection were less frequent, survivors eligible for benefits under the Black Lung Benefits Act would not be able to exercise their right to apply.
Explain any special circumstances required in the conduct of this information collection.
There are no special circumstances for conducting this information collection.
If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
A Federal Register Notice inviting public comment was published on December 3, 2019 [84 FR 66219]. No comments were received.
Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
Respondents do not receive any gifts or payments to furnish the requested information.
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
The information collected is covered by two the Privacy Act System of Records, DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25858 and 25866 (April 29, 2016), or as updated and republished.
Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
There are no questions of a sensitive nature on this form.
Provide estimates of the hour burden of the collection of information. The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information.
The burden estimate for the CM-912 is based upon approximately 850 forms received yearly by DCMWC district offices. A survivor needs to fill out an application only once. It takes approximately 8 minutes per response, for a total annual burden of 113 hours.
(850 forms x 8 min= 6,800 min/60 = 113 hours (113.33 rounded down)
The estimated total cost to respondents for the burden hours is approximately $515. The cost is computed by using the hourly Black Lung beneficiary benefit rate of $4.56. ($669 monthly x 12 = $8,028 a year/220 OPM annual workdays = $36.49 a day/8 work hours a day = $4.56 hourly. $4.56 x 113 work hours = $515.28 or $515, rounded down). https://www.ecfr.gov/cgi-bin/text-idx?SID=29bc2eece4de07711e99fe94392c8bf3&mc=true&node=se20.4.725_1520&rgn=div8
Annual Costs to Respondents (capital/start-up & operation and maintenance). Provide an estimate for the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden already reflected on the burden worksheet). The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life) and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities. If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collections services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate. Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.
Operation and maintenance costs consist of mailing costs for the form. Approximately 200 of the forms are completed at Black Lung or SSA offices and thus incur no mailing costs. About 650 of the completed responses are mailed to the Black Lung offices at a cost of $.58 ($.55 postage and .03 for the envelope), for a total of $377.00. ($.58 x 650 = $377.00)
Provide estimates of annualized cost to the Federal government.
The estimated total cost to the Federal government for this information collection is approximately $11,796.25. The cost is computed as follows:
a. Estimated mailing cost: $377.00
(Stamps ($.55) and envelopes ($.03) @ $.58 for 650 forms sent to the claimant for completion, this excludes the approximate 200 forms completed at a Black Lung office)
b. Estimated processing cost: $8,609.00
(claims staff, GS-12/5, spends about 15 minutes evaluating each form: $40.51 x 850 = 34,434 (rounded up from 34,433.5)/4 = $8,609 (rounded up from 8,608.5) https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2019/RUS_h.pdf
c. Estimated SSA contract costs: $2,810.25
(SSA is under contract with DCMWC for claim taking services at SSA district offices throughout the country. The price per claim intake is $37.47. Of the 200 responses taken at DCMWC or SSA offices, it is estimated that approximately 75 will be taken by SSA. (75 x $37.47 = $2,810.25)
Explain the reasons for any program changes or adjustments.
Fewer CM-912s were completed during the past year.
Updates made to form CM-912:
-Privacy Act Notice updated.
-Added address where to mail completed form.
For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
There are no plans to publish this collection of information.
If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
This ICR does not seek a waiver from the requirement to display the expiration date.
Explain each exception to the certification in ROCIS.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods.
Statistical methods are not used in these collections of information.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | US Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |