Application for Self-Insurance Under the Black Lung Benefits Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-2017A Application for Self-Insurance Under the black Lung Benefits Act	Form and Instruction	Modified	Repair queued
Supporting Statement 1240-0057 7-6-2022.docx	Supporting Statement A	Uploaded 2022-07-06	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234819	Application for Self-Insurance Under the black Lung Benefits Act	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0057	ICR Reference No: 202201-1240-003
Status: Received in OIRA	Previous ICR Reference No: 201901-1240-008
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Application for Self-Insurance Under the Black Lung Benefits Act
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/11/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2022
Responses	294	318
Time Burden (Hours)	261	283
Cost Burden (Dollars)	34,080	145

---

Abstract: This information collection is essential to the mission of OWCP’s Division of Coal Mine Workers’ Compensation, which administers the Black Lung Benefits Act (BLBA), 30 U.S.C. 901 et seq. The statute grants the Department authority to authorize and regulate coal mine operators who wish to self-insure their BLBA liabilities. 30 U.S.C. 933. This information collection would provide OWCP with sufficient information to determine whether a coal mine operator should be (or continue to be) authorized to self-insure. The information would also allow OWCP to determine the security amount a coal mine operator must deposit to guarantee that it will be able to meet its BLBA liabilities.

---

Authorizing Statute(s): US Code: 30 USC 933 Name of Law: Black Lung Benefits Act (BLBA)
  

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:
	87 FR 11738	03/02/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 41146	07/11/2022
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
Application for Self-Insurance Under the black Lung Benefits Act	CM-2017A, CM-2017B, CM-2017	Report of Claims Information ,   Report of Claims Information ,   Application or Renewal of Self-Insurance Authority

---

ICR Summary of Burden

table that charts list of burden

	Total Request	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	294	318	0	-24	0	0
Annual Time Burden (Hours)	261	283	0	-22	0	0
Annual Cost Burden (Dollars)	34,080	145	0	33,935	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated number of self-insure applicants has decreased from 53 to 49. The respondents estimated annualized value of the burden hours has decreased due to the number of applications for self-insurance received. Annual costs to respondents decreased because the number of applicants is lower.

---

Annual Cost to Federal Government: $15,866

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]? No

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: 07/11/2022

---