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Description of Coal Mine Work and Other Employment

OMB: 1240-0035

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Description of Coal Mine Work and Other Employment

OMB Control Number: 1240-0035

OMB Expiration Date: 10/31/2023



OMB CONTROL NO. 1240-0035

This ICR seeks a revision to the currently approved version.


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.

Information collected on the OWCP Form, CM-913 helps the Division of Coal Mine Workers’ Compensation (DCMWC) determine if the miner has or had a reduced ability to perform his usual coal mine work or comparable non-coal mine work, a criterion for entitlement under the Black Lung Benefits Act, 30 U.S.C. 901 (a)(b). The implementing regulations authorize the collection of this information. See 20 CFR 718.204(b)(1) and 725.405(d).

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 completed form is evaluated by the claims staff to determine if the miner has or had a reduced ability to perform his or her usual coal mine work or comparable non-coal mine work.

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 to adopt this means of collection. Also, describe any consideration of using information technology to reduce burden.

The CM-913 is available on the Internet for downloading at: The form can be completed on-screen, printed, and mailed. The form can also be printed, hand completed, and submitted electronically through the COAL Mine Portal (

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.

Collection of this information is from individuals only. It does not involve small businesses or other small entities, so this information collection does not have a significant impact on a substantial number of 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.

The information for each form CM-913 is collected only once per claim. If the information were not collected, DCMW would be unable to determine whether the miner could perform his usual coal mine employment or comparable gainful employment. DCMWC is required to make this determination in determining a miner’s eligibility for benefits under the Black Lung Benefits Act.

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 May 9, 2023 (88 FR 29952). Comments were not received.

OWCP has not consulted with the public for this specific ICR during the last 3-year period. We are in the process of reviewing all our ICR requirements and implementing procedures to comply with M-22-10 for any ICR’s submitted to OMB after Oct. 1, 2023, and will continue consultations thereafter.

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

Respondents do not receive 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 Systems of Records, DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25765, 25858 and 25866 (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 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.1

  • 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 13.

Estimated Annualized Respondent Cost and Hour Burden


No. of Respondents

No. of Responses

per Respondent

Total Responses

Average Burden (Hours)

Total Burden (Hours)


Wage Rate

Monetized Value of Respondent Time

OWCP Form CM-913








The estimated total burden to claimant respondents is 2,355 hours. A claimant needs to fill out the CM-913 only once. It takes about 30 minutes (0.5 hour) to complete and electronically file or mail each of the approximately 4,710 CM-913 forms received annually.

CM-913: 4,710 responses x .5 hours/response = 2,355 burden hours.

The estimated total cost to respondents for the burden hours is approximately $13,800.30. The cost is computed by using the hourly Black Lung beneficiary benefit rate of $5.86. ($860 benefits/month × 12 months/year = $10,320 benefits/year; $10,320 benefits/year ÷ 220 OPM workdays/year = $46.90 benefits/day; $46.90 benefits/day ÷ 8 workhours/day = $5.86 benefits/hour. ) $5.86/hour x 2,355 burden hours = $13,800.30 burden cost of time). and

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, 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.

Respondent’s cost to mail each response is estimated at 69¢ (66¢ stamp plus 03¢ for the envelope). Responses mailed would yield a total respondent cost of $3,250 rounded (4,710 x 69¢ = $3,249.90) if there were no electronic submissions.

However, of the 4,710 responses that will be sent to DCMWC, it is estimated that 20% will be submitted electronically through the COAL Mine Portal (4,710 x 20% = 942). The estimated savings of the forms submitted through the COAL mine portal is $649.98 (942 x 69¢=$649.98). The remaining 3,768 responses will be mailed to DCMWC with a respondent cost of $2,599.92 (3,768 x 69¢ = $2,599.92) or $2,600 (rounded up).

Therefore, the total respondent cost is $ 2,600 (rounded).

There are no other known operating or maintenance costs associated with this collection.

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), and 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.

The estimated total cost to the Federal government for this information collection of these 4,710 forms is approximately $56,073. The cost is computed as follows:

a. Estimated mailing cost: $3,109

(Stamps and envelopes ¢ .66 (63¢ metered postage + ¢.3 envelope) x 4,710 = $3,108.60 or $3,109 (rounded up))

b. Estimated processing cost: $52,964

One Claims’ Examiner GS-12/5 (CE) spends about 15 minutes (0.25 hour) evaluating each of the 4,710 forms. Therefore: 4,710 forms x 0.25 CE hours/form x $44.98/CE hour = $52,963.95 or $52,964.00 (rounded up).

$3,109 mailing cost + $52,964 processing cost = $56,073 total cost.

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


Respondents: The number of respondents decreased from 6,100 to 4,710. The number of respondents decreased due to a decrease of claims field.

The following also decreased due to a decrease in number of forms received/responses.

Responses: Responses have decreased from 6,100 to 4,710.

Burden Hours: Burden hours have decreased from 3,050 to 2,355.

Costs: Annual burden costs have decreased from $3,515 to $2,600.

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 the results of 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 information collection request 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.


Statistical methods are not used in these collections of information.

1 Indicate the retention period for any recordkeeping requirements that pertain to the ICR.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMarch 6, 2007
AuthorTheda Kenney
File Modified0000-00-00
File Created2023-09-14

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