2022 Supporting Statement 1240-0038 FINAL

Miner’s Claim for Benefits Under the Black Lung Benefits Act and Employment History

OMB Control Number 1240-0038

OMB Expiration Date: 2022

SUPPORTING STATEMENT FOR

Miner’s Claim for Benefits under the Black Lung Benefits Act and Employment History

OMB CONTROL NO. 1240-0038

This ICR is being submitted as a Revision. The changes clarify certain questions and disclosures. These are more fully discussed in item 15 of this Supporting Statement.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

CM‑911

The Black Lung Benefits Act (BLBA), 30 USC 901 et seq., provides monthly disability benefits to coal miners who are totally disabled due to pneumoconiosis (black lung disease) and to certain survivors of miners. Miners entitled to benefits also receive medical benefits for treatment related to their pneumoconiosis and resulting disability.

A miner who applies for black lung benefits must complete the CM‑911 (application form). The completed form gives basic identifying information about the applicant and is the beginning of the development of the black lung claim. Regulations 20 CFR 725.304a authorizes this information collection.

CM‑911a

An applicant filing for black lung benefits must complete a CM‑911a at the same time the black lung application form is submitted. This form, when completed, provides a complete history of the miner’s employment and helps to establish whether the individual currently or formerly worked in the nation's coal mines and how long that employment lasted. Regulation 20 CFR 725.404(a) authorizes this information collection.

The collection of the coal miner’s Social Security Number (SSN) is necessary because of offset provisions in the laws for both the Social Security Administration and the BLBA to prevent overpayments and duplicate benefits. The Division of Coal Mine Workers’ Compensation does not list the SSN on outgoing correspondence, but rather uses a computer generated DOL Case ID Number. 

The SSN is also needed to coordinate medical treatment benefits between the Black Lung Program and other health care insurers to prevent duplicate reimbursement. Because the universal billing form (CMS-1500) and DCMWC’s version (OWCP-1500) both use the SSN, it would be almost impossible to properly pay medical providers for treatment services given to disabled miners without it.

2. 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.

CM‑911

Upon completion by the applicant and receipt of the CM‑911 by the Black Lung District Office, the claims staff reviews the information and begins the verification process of each item on the application. For example, the claims staff requests copies of the birth and marriage records to establish dependency and to help determine the potential amount of benefits to which the miner would be entitled. Upon receipt and verification of all items requested, the claims staff can determine if the applicant meets the statutory criteria for an award of benefits. If this information were not collected and the miner's signature were not obtained on the CM‑911, the requirements of the Black Lung Benefits Act would not be met.

CM‑911a

Once the CM‑911a is completed and received in the black lung office, the claims staff reviews and verifies the information to determine if coal mine employment is established. Other types of employment are also reviewed to help establish total disability due to coal mine employment. Proof of coal mine employment is a major element in establishing a causal relationship between employment and total disability due to pneumoconiosis for entitlement purposes. If this information were not gathered, neither coal mine employment nor the length of that employment could be established.

3. 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.

Both forms are available for downloading at http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm. They can also be accessed through the Department of Labor’s on-line forms library at http://webapps.dol.gov/libraryforms/

The forms can be filled out on-screen, printed, and mailed or may be printed, completed by hand, and mailed. The completed forms may also be submitted online through the COAL Mine Portal at https://eclaimant.dol.gov/portal/?program_name=BL .  It has been made available for electronic submission.

Each form requires the signature of the claimant, which could be affixed electronically, but also contains a space for the signatures of two witnesses if the claimant is unable to sign his or her name.  Three independently-obtained digital signatures by different people would be required to submit such a form on-line and, in order to keep claim information confidential, the Department of Labor’s website does not permit forwarding or submission of on-line forms to any place other than the Department’s designated electronic mailbox.  This would prevent the claimant from forwarding the form to the witness after both had received their digital signature verification keys.

4. 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 information available.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information is provided by individuals; thus, its collection does not impact small entities.

6. Describe the consequence to 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 information is collected only at the time of application. If it were collected less frequently, this information would not be available for case adjudication.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for this information collection.

8. 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. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting public comment was published on 07 October 2021 (86 FR 55862). No public comments were received.

9. Explain any decision to provide any payments or gifts to respondents, other than remuneration of contractors or grantees.

Respondents do not receive any gifts or payments to furnish the requested information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

Since the completed forms are maintained in the claimant’s case file, the information collected is covered by the Privacy Act System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished. The Privacy Act notice on the forms let users know under what circumstances information may be released.

11. 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.

This collection contains no questions of a sensitive nature.

12. 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 conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Total Burden Cost
CM-911	4,900	1	4,900	45 min.	3,675	$7.25	$26,643.75
CM-911a	4,900	1	4,900	40min	3,267 (rounded)	$7.25	$23,678.50
Unduplicated Total	4,900	2	9,800		6,942

CM‑911

The estimated burden of this information collection is approximately 3,675 hours. This burden is based on a submission of 4,900 CM‑911's with 45 minutes to read and complete the form. Local Social Security Offices or Black Lung Offices supply the form and help the claimant complete the form.

45 minutes x 4,900 forms = 3,675 total burden hours.

For the burden cost to the applicant, we use the 2021 Federal minimum wage of $7.25 per hour. https://www.minimum-wage.org/federal

3,675 burden hours x $7.25 per hour = $26,643.75

CM‑911a

The estimated burden of this information collection is approximately 3,266 hours. This burden is based on a submission of 4,900 CM‑911a's with 40 minutes to read and complete the form. Local Social Security Offices or Black Lung Offices supply the form and help the claimant complete the form.

40 minutes x 4,900 forms = 3,267 total burden hours.

For the burden cost to the applicant, we use the 2021 Federal minimum wage of $7.25 per hour. https://www.minimum-wage.org/federal

3,267 burden hours x $7.25 per hour = $23,685.75

Total Time Burden:

4,900 Respondents

9,800 Responses

6,942 Hours (3,675 CM-911 and 3,267 CM-911a)

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• 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 service 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 collection 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.

Since the CM-911 and the CM-911a are generally completed and returned at the same time, no additional mailing costs appear for the CM-911a. An estimated 70% (4,900 X 70% = 3,430) of the respondents mail their response, and the cost is estimated at 53 cents per respondent for postage and envelope. The remaining 30% of respondents provide their information electronically through the Coal Mine Portal. The cost is as follows:

CM-911: 3,430 x $.53 ($.50 postage + $ .03 envelope) = $1,818.00

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

a. Estimated mailing cost: $ $1,299

An estimated 50% (2,450) of the CM-911 and CM-911a are sent together to the black lung applicants, and the cost is estimated at 53 cents per applicant for postage and envelope. The total mailing cost is $1,299.00 (rounded up).

The cost is figured as follows:

2,450 x .53 (.50 postage + .03 envelope) = $1,299.00

b. Estimated processing cost: $206,192.

GS‑12/5 spends about 1 hour for review of the two forms per respondent.

$42.08 x 4,900 = $206,192

The hourly rate is taken from Salary Table 2021GS–RUS. https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/RUS_h.pdf

The total Federal cost is $207,491. (Processing costs + postage).

15. Explain the reasons for any program changes or adjustments.

The annual number of responses decreased by 40 from 9,840 to 9,800. This decrease is a result of fewer claims filed. The increase in hour burden is the result of a previous error in the calculation. The estimated cost for operations and maintenance has increased from $1,790.00 to $1,818.00 due to increased cost of postage.

The following updates were made to the forms. The revisions made to the form do not impact the time it takes to complete the form.:

CM-911

7.a. fillable box.

7.b. fillable box and change language to “In what State of the United States were you in when you stopped working in or around coal mines or a coal preparation facility in the extraction, transportation or preparation of coal, or in coal mine construction or maintenance in or around a coal mine? “

7.c. change the language to “Why did you stop working in or around coal mines or in a coal preparation facility in the extraction, transportation or preparation of coal, or in coal mine construction or maintenance in or around a coal mine?”

7.d. add a new box on the form Have you ever been transferred from your regular coal mine job to lighter duty?

 Yes  No If “Yes,” provide the dates and reasons

why you were transferred. Use space in

item 18, “Remarks.”

13. Change language to “have you ever been previously married?”

19. Eliminate

20. Eliminate

Change current language under “Signature of Miner” from:

“I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief. I am also fully aware that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this title shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of not more than $1,000.00, or by imprisonment for not more than one year, or both”.

To:

“I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief. I am also fully aware that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this title shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of not more than $1,000.00, or by imprisonment for not more than one year, or both. I authorize any physician, hospital, agency, employer or other organization (including the Social Security Administration) to disclose any medical records, or other information to the Department of Labor, Office of Workers’ Compensation Programs. Furthermore, I authorize the Department of Labor, Office of Workers’ Compensation Programs to disclose any medical or other information about the decision in your Black Lung Benefits claim to the Workers’ Compensation, Unemployment Compensation, or Disability Insurance agency of my State to use in connection with any claim with another agency”.

26. add box for “Claimant’s Email Address”.

Add on last page of form:

TWO FILING OPTIONS:

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal: https://eclaimant.dol.gov/portal/?program_name=BL

2. To file by mail, use the enclosed envelope to submit completed form and accompanying documentation to:

U.S. Department of Labor OWCP/DCMWC

Central Mail Room

PO Box 8307

London, KY 40742-8307

CM-911a

13. add box for “Claimant’s Email Address”.

Add on last page of form:

TWO FILING OPTIONS:

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal: https://eclaimant.dol.gov/portal/?program_name=BL

2. To file by mail, use the enclosed envelope to submit completed form and accompanying documentation to:

U.S. Department of Labor OWCP/DCMWC

Central Mail Room

PO Box 8307

London, KY 40742-8307

16. For collections of information whose results will be published, outline plans for tabulations, 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 of information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. 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.

18. Explain each exception to the certification statement.

There are no exceptions to the certification statement.

2. COLLECTIONS OF INFORMATON EMPLOYING STATISTICAL METHODS. Statistical methods are not used in these collections of information.

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