OWCP Black Lung Worker's Compensation Program End-to-End Experience Customer Interviews

Improving Customer Experience (OMB Circular A-11, Section 280 Implementation) for the Department of Labor (DOL)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1225-0093 can be found here:

Documents and Forms

Document Name Document Type
Claimant Interview Guide- Black Lung.docx Instruction
Claimant Interview Guide- Black Lung.docx Instruction
Consent Form_ Black Lung.docx Black Lung Consent Form IC Document
Consent Form_ Black Lung.docx Black Lung Consent Form IC Document
ICR DOL OWCP BlackLung Program Supporting Statement.docx 1225-0093 Supporting Statement - Black Lung End-to-End Experience Interviews IC Document
ICR DOL OWCP BlackLung Program Supporting Statement.docx 1225-0093 Supporting Statement - Black Lung End-to-End Experience Interviews IC Document

Information Collection (IC) Details

IC Title:	OWCP Black Lung Worker's Compensation Program End-to-End Experience Customer Interviews	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Claimant Interview Guide- Black Lung.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Requested	Previously Approved
Annual Number of Responses for this IC	16	16
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Black Lung Consent Form	Consent Form_ Black Lung.docx	10/26/2022
1225-0093 Supporting Statement - Black Lung End-to-End Experience Interviews	ICR DOL OWCP BlackLung Program Supporting Statement.docx	10/26/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.