Notice to Reviewer

NOTICE TO REVIEWER

Date: March 16, 2015

Request Type:  No material or non-substantive change to a currently approved collection

Employing Agency:  Office of Workers’ Compensation Programs/Division of Coal Mine Workers’ Compensation (DCMWC)

Form Number/Name:  CM-988, CM-2907, CM-933, CM-933b, and CM-1159 Medical History and Examination for Coal Mine Workers’ Pneumoconiosis, Report of Ventilatory Study, Roentgenographic Interpretation, Roentgenographic Quality Rereading, and Report of Arterial Blood Gas Study.

OMB/Expiration Date:  1240-0023, May 31, 2017

Justification:

DCMWC is seeking approval for the forms CM-988, CM-2907, CM-933, CM-933b, and CM-1159.

When a miner applies for benefits, the Division of Coal Mine Workers' Compensation (DCMWC) is required to schedule a series of four diagnostic tests to help establish eligibility for black lung benefits.  Each of the diagnostic tests has its own form that sets forth the medical results.

Minor ecstatic changes were made to the forms in order to assist medical providers when completing these forms.

CM-933 and CM-933b – Roentgenographic was changed to Radiologic, Film/films was changed to image/images, typos were corrected, added “Date current B-reader certification expires”, and Privacy Act Notice and Accommodation Statement added.

CM-2907 – Privacy Act Notice and Accommodation Statement added.

CM-1159 – Bolded two sentences, enlarged the size of asterisks, typo corrected, and Privacy Act Notice and Accommodation Statement added.

CM-988 – Bolded existing language, moved numerous questions inside of block (rather than outside of block), renumbered two questions, and

Privacy Act Notice and Accommodation Statement added.