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1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History
Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
OMB: 1240-0038
IC ID: 13681
OMB.report
DOL/OWCP
OMB 1240-0038
ICR 202311-1240-003
IC 13681
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0038 can be found here:
2024-03-13 - No material or nonsubstantive change to a currently approved collection
2024-01-31 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form CM-911
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History
Form
CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits Act
CM-911 Final KL 11-2-2023_MN-MM.docx
www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Form
Information Collection (IC) Details
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