Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-623S Representative Payee Report (short version)	Form	Modified	Available
Form CM-623 Representative Payee Report	Form	Modified	Available
Form CM-787 Physician's/Medical Officer's Statement	Form	Modified	Available
Form CM-787 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form	Modified	Repair queued
SS 1240-0024 CM-893 2023 final.docx	Supporting Statement A	Uploaded 2024-03-18	Repair queued
60-day FRN (1240-0020) published.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
20 CFR 725.506.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
20 CFR 725.513.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
20 CFR 725.512.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
20 CFR 725.511.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
20 CFR 725.510.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
30 USC Subchapter IV (Sections 901-951).pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
30-day FRN (1240-0020) published.pdf	Supplementary Document	Uploaded 2021-03-15	Repair queued
System of Record Notice.pdf	Supplementary Document	Uploaded 2017-12-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form	Modified	Representative Payee Report (short version)
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form	Modified	Representative Payee Report
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form	Modified	Physician's/Medical Officer's Statement
13881	Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	Form	Modified

ICR Details

OMB Control No: 1240-0020	ICR Reference No: 202311-1240-007
Status: Active	Previous ICR Reference No: 202012-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/01/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/29/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2027	36 Months From Approved	05/31/2024
Responses	282	0	1,325
Time Burden (Hours)	154	0	679
Cost Burden (Dollars)	192	0	769

---

Abstract: Representative Payee Report (CM-623) and Representative Payee Report Short Form (CM-623S) are used to ensure that benefits paid to a representative payee are being used for the beneficiary's well-being. Physician's/Medical Officer's Statement (CM-787) is used to determine the beneficiary's capability to manage monthly Black Lung benefits.

---

Authorizing Statute(s): US Code: 30 USC 922 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 2254	01/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 22179	03/29/2024
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement	CM-787, CM-623, CM-623S	Physician's/Medical Officer's Statement ,   Representative Payee Report ,   Representative Payee Report (short version)

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	282	1,325	0	0	-1,043	0
Annual Time Burden (Hours)	154	679	0	0	-525	0
Annual Cost Burden (Dollars)	192	769	0	0	-577	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: No

Burden Reduction Due to:

Short Statement: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents decreased from 1,325 to 282. Due to less beneficiaries needed a rep payee. Responses: The number of responses decreased from 1,325 to 282. Due to less forms submitted. Burden Hours: Total burden hours decreased from 679 to 153 due to the decrease of forms received. Costs: Annual burden costs decreased from $769 to $192 due to a decrease of responses submitted.

---

Annual Cost to Federal Government: $4,109

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]? No

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

---

Common Form ICR:  No

---

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: 03/29/2024

---