Claim Adjudication Process for the Alleged Presence of Pneumoconiosis

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified	Available
2023_30-Day FRN_1240-0023.pdf	Supplementary Document	Uploaded 2023-10-04	Repair queued
SS 1240-0023 2023_MN-MM.docx	Supporting Statement A	Uploaded 2023-09-28	Available
FRN 1240-0023 2023.docx.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2023-09-28	Missing upstream
725.406.pdf	Supplementary Document	Uploaded 2020-05-04	Repair queued
718.204.pdf	Supplementary Document	Uploaded 2020-05-04	Repair queued
718.202.pdf	Supplementary Document	Uploaded 2020-05-04	Repair queued
DOL-OWCP-9.pdf	Supplementary Document	Uploaded 2020-05-04	Repair queued
CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis.pdf	Supplementary Document	Uploaded 2020-02-19	Repair queued
DOL-OWCP-2.pdf	Supplementary Document	Uploaded 2020-05-04	Repair queued
1240-0023 20CFR718.101 - 105.pdf	Supplementary Document	Uploaded 2011-05-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13765	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form	Modified

ICR Details

OMB Control No: 1240-0023	ICR Reference No: 202306-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202005-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim Adjudication Process for the Alleged Presence of Pneumoconiosis
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/04/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2023
Responses	21,500	30,000
Time Burden (Hours)	5,232	7,300
Cost Burden (Dollars)	0	0

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Abstract: As part of the claim adjudication process, 20 CFR 718 requires certain medical information be obtained regarding the medical condition of a claimant alleging the presence of pneumoconiosis. The medical specifications in the regulations have been formatted in a variety of forms to promote efficiency and accuracy in gathering the required data. These forms were designed to meet the need to gather medical evidence.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act of 1977, as amended
   US Code: 30 USC 923(b) Name of Law: Black Lung Benefits Act of 1977, as emended
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 41420	06/26/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 68673	10/04/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	CM-933, CM933b, CM-988, CM-1159, CM-2907	Roentgenographic Interpretation ,   Roentgenographic Quality Rereading ,   Medical History and Examination for Coal Mine Workers' Pneumoconiosis ,   Report of Arterial Blood Gas Study ,   Report of Ventilatory Study

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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	21,500	30,000	0	-8,500	0	0
Annual Time Burden (Hours)	5,232	7,300	0	-2,068	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents decreased from 30,000 to 21,500. The number of respondents decreased due to a decrease of claims field. Responses: Responses have decreased from 30,000 to 21,500 due to a decrease in number of forms received/responses. Burden Hours: Burden hours have decreased from 7,300 to 5,232. Costs: Annual burden costs remains $0 since the Department of Labor pays a flat fee for mailing and handling.

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Annual Cost to Federal Government: $5,747,492

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]? Yes

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

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Common Form ICR:  No

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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: 10/04/2023

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