NON- SUBSTANTIVE CHANGE REQUEST FOR THE MINER’S CLAIM for BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-911 AND EMPLOYMENT HISTORY CM-911a OMB CONTROL NO. 1240-0038 (October 2023)

NON- SUBSTANTIVE CHANGE REQUEST FOR THE MINER’S CLAIM for BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-911 AND EMPLOYMENT HISTORY CM-911a

OMB CONTROL NO. 1240-0038 (October 2023)

DCMWC is requesting a non-substantive change to the recently approved collection of information contained in “Miner’s Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a” to correct typographical errors in the CM-911 Form.

DCMWC seeks to revise the recently approved CM-911 as follows:

• Item 10: Change parenthetical reference from “in Item 25,” to “in Item 23”

• Item 16: Change parenthetical directive from “If ‘Yes,’ complete items a through j” to “If ‘Yes,’ complete items a through k”

• Item 17: Change parenthetical directive from “If ‘No,’ go to item 17” to “if ‘No,’ go to item 18”

• Item 21: Change “Use ‘remarks’ space in item 22 if the space below is insufficent ” to “Use ‘remarks’ space in item 23 if the space below is insufficient”
  
  
  

This change request does not affect the burden hours. The burden hours remain the same.

The revised form is attached to this change request.