Claim Adjudication Process for Alleged Presence of Pneumoconiosis

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-988 Medical History and Examination for Coal Mine Workers Pneumoconiosis	Form and Instruction	Modified	Repair queued
Form CM-2907 Report of Ventilatory Study	Form and Instruction	Modified	Available
Form CM-1159 Report of Arterial Blood Gas Test	Form and Instruction	Modified	Available
Form CM-933b Radiologic Quality Rereading	Form and Instruction	Modified	Available
Form CM-933 Radiologic Interpretation	Form and Instruction	Modified	Available
Justification - Medical History and Examination for Coal Mine Workers Pneumoconiosis (CM-988).docx	Supplementary Document	Uploaded 2020-11-04	Available
20200512 SS 1240-0023 SS Determination Forms-with 60-day FRN.docx	Supporting Statement A	Uploaded 2020-05-12	Available
725.406.pdf	Supplementary Document	Uploaded 2020-05-04	Available
718.204.pdf	Supplementary Document	Uploaded 2020-05-04	Available
718.202.pdf	Supplementary Document	Uploaded 2020-05-04	Available
DOL-OWCP-9.pdf	Supplementary Document	Uploaded 2020-05-04	Available
Justifiction - CM-988.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-02-19	Available
CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis.pdf	Supplementary Document	Uploaded 2020-02-19	Available
DOL-OWCP-2.pdf	Supplementary Document	Uploaded 2020-05-04	Available
1240-0023 20CFR718.101 - 105.pdf	Supplementary Document	Uploaded 2011-05-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13765	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form and Instruction	Modified	Medical History and Examination for Coal Mine Workers Pneumoconiosis
13765	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form and Instruction	Modified	Report of Ventilatory Study
13765	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form and Instruction	Modified	Report of Arterial Blood Gas Test
13765	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form and Instruction	Modified	Radiologic Quality Rereading
13765	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form and Instruction	Modified	Radiologic Interpretation

ICR Details

OMB Control No: 1240-0023	ICR Reference No: 202005-1240-001
Status: Historical Active	Previous ICR Reference No: 202002-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim Adjudication Process for Alleged Presence of Pneumoconiosis
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: 12/30/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/19/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved	12/31/2020
Responses	30,000	0	27,500
Time Burden (Hours)	7,300	0	6,693
Cost Burden (Dollars)	0	0	0

---

Abstract: Request for 20 CFR 718 specifies that certain information relative to the medical condition of a claimant who is alleging the presence of pneumoconiosis be obtained as a routine function of the claim adjudication process. The medical specifications in the regulations have been formatted in a variety of forms to promote efficiency and accuracy in gathering the required data. These forms were designed to meet the need to gather medical evidence.

---

Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act of 1977, as amended
   US Code: 30 USC 923(b) Name of Law: Black Lung Benefits Act of 1977, as emended
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 27775	05/11/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 50837	08/18/2020
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	CM-988, CM-2907, CM-933, CM-933b, CM-1159	Radiologic Interpretation ,   Radiologic Quality Rereading ,   Report of Arterial Blood Gas Test ,   Report of Ventilatory Study ,   Medical History and Examination for Coal Mine Workers Pneumoconiosis

---

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	30,000	27,500	0	0	2,500	0
Annual Time Burden (Hours)	7,300	6,693	0	0	607	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The annual number of responses changed slightly to 30,000 from 27,500, estimated total burden hours changed to 7,300 hours from 6,693 hours due to the increase of completing and mailing each form.

---

Annual Cost to Federal Government: $6,810,218

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]? Yes

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

---

Common Form ICR:  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:

(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: 08/19/2020

---