Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

Claim Adjudication Process for Alleged Presence of Pneumoconiosis

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0023 can be found here:

Documents and Forms

Document Name Document Type
Form CM-988 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
CM-933 Radiologic Interpretation 20200430 CM-933.docx www.dol.gov/owcp/regs/compliance/cm-933.pdf Form and Instruction
CM-933b Radiologic Quality Rereading 20200430 CM-933b.docx www.dol.gov/owcp/regs/compliance/cm-933b.pdf Form and Instruction
CM-1159 Report of Arterial Blood Gas Test 20200430 CM-1159.docx wwwldol.gov/owcp/regs/compliance/cm-1159.pdf Form and Instruction
CM-2907 Report of Ventilatory Study 20200430 CM-2907.docx www.dol.gov/owcp/regs/compliance/cm-2907.pdf Form and Instruction
CM-988 Medical History and Examination for Coal Mine Workers Pn 1240-0023 Medical History and Examination for Coal Mine Workers Pneumoconiosis (CM-988).pdf www.dol.gov/owcp/regs/compliance/cm-988cm-988a.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 718.102-105 20 CFR 725.406 20 CFR 718.202 20 CFR 718.204

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-988	Medical History and Examination for Coal Mine Workers Pneumoconiosis	1240-0023 Medical History and Examination for Coal Mine Workers Pneumoconiosis (CM-988).pdf	http://www.dol.gov/owcp/regs/compliance/cm-988cm-988a.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-933	Radiologic Interpretation	20200430 CM-933.docx	http://www.dol.gov/owcp/regs/compliance/cm-933.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-933b	Radiologic Quality Rereading	20200430 CM-933b.docx	http://www.dol.gov/owcp/regs/compliance/cm-933b.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-1159	Report of Arterial Blood Gas Test	20200430 CM-1159.docx	http://wwwldol.gov/owcp/regs/compliance/cm-1159.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-2907	Report of Ventilatory Study	20200430 CM-2907.docx	http://www.dol.gov/owcp/regs/compliance/cm-2907.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2 and DOL/OWCP-9	FR Citation: 67 FR 16869

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30,000	2,500	27,500
Annual IC Time Burden (Hours)	7,300	607	6,693
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.