Supporting Statement - 1240-0034 Final

Authorization for Release of Medical Information (Black Lung Benefits) OMB Control Number 1240-0034

OMB Expiration Date: February 2022

SUPPORTING STATEMENT

Authorization for Release of Medical Information (Black Lung Benefits)

OMB Control No. 1240-0034

1. Justification:

1. 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.

Claims under the Black Lung Benefits Act (BLBA), 30 USC 901 et seq., generally require consideration of medical information about the miner. When a claimant wants existing medical data to be considered, an executed CM-936 form authorizes physicians, hospitals, medical facilities or organizations, and the National Institute of Occupational Safety and Health to release medical information about the miner to the Office of Workers’ Compensation Programs (OWCP). The BLBA, 30 USC 923(b), and the implementing regulations, 20 CFR 725.405, authorize this information collection because they require that all relevant medical evidence be considered in deciding a claimant's eligibility for benefits.

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.

The claimant uses the CM-936 form to authorize physicians, hospitals, medical facilities or organizations, and the National Institute of Occupational Safety and Health to release medical information about the miner to OWCP. The form may be completed by the claimant or claims staff. If the claims staff completes the form from information already in the claim file, the claimant must verify and sign the authorization.

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.

In accordance with the Government Paperwork Elimination Act (GPEA), Form CM-936 is electronically interactive and is posted on the internet at http://www.dol.gov/owcp/regs/compliance/cm-936.pdf. The form may also be completed from a printed copy. The completed form may be mailed to OWCP or filed electronically through the COAL Mine Portal at https://eclaimant.dol.gov/portal/?program_name=BL

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 2 above.

The Federal Black Lung Program has no other medical release form. Other programs have medical release forms; however, they are program-specific for covered occupational illnesses and do not specifically request medical evidence related to the adjudication of black lung claims. There is no similar information available.

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

This information does not have a significant impact on a substantial number of small entities.

6. 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.

If this form were not used, the adjudication of the black lung claim would be incomplete, because pertinent medical data would not be available for consideration.

7. Explain any special circumstances required in the conduct of this information collection.

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.

A Federal Register Notice inviting public comment was published on September 13, 2021 (85 FR 50909). The agency received no public comments in response to this notice.

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

No payments or gifts are made to respondents to furnish the information.

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

Since the completed form is maintained in the beneficiary’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.

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 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-936	5,000	1	5,000	5 min.	417	$7.25	$3,023.00

There are approximately 5,000 respondents annually. One form is sent to each respondent, who spends approximately 5 minutes to complete and submit the form. Thus, there is an annual burden of 417 hours (5,000 X 5 minutes = 25,000 minutes/60 minutes in an hour = 417 hours).

To estimate the annual cost of the burden hours to the CM-936 respondents, the Federal minimum wage of $7.25 per hour, has been applied. Verification was obtained from https://www.dol.gov/agencies/whd/mw-consolidated. Thus, the total annual cost to CM-936 respondents is $3,024 (rounded up) ($7.25 X 417 burden hours).

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

The federal government provides prepaid postage for the claimants to return the forms. As a result, there is no cost burden on respondents.

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.

Estimated mailing cost is $5,000.00 (includes cost of envelope and stamp, and return stamped envelope, at .53 cents per stamped envelope) (.50 cents per stamp plus .03 cents per envelope.) (.53 X 5,000)= $2,650.00 X 2 = $5,300.00)

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

There has been a decreased in the number of respondents, as well as the burden hours. This is due to the decrease in the number of claims filed during the pandemic.

16. 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.

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 identified in ROCIS.

There are no exceptions to the certification statement.

2. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

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