Information Collection

DOL OWCP Black Lung - Claimants with Pending Claim

IC 259961 under ICR 202312-1225-004 · OMB 1225-0093.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DOL OWCP Black Lung - Claimants with Pending Claim	Form
Black Lung Survey- Pending Claim - Instructions Updated 5-1-2023 (002).docx	Instruction
Black Lung Survey- Pending Claim - Instructions Updated 5-1-2023 (002).docx	Instruction
OWCP Black Lung CX Survey - Claimants with a Pending Cla CX Survey-Claimants with a Pending Claim 5-1-2023.docx	Form
OWCP Black Lung CX Survey - Claimants with a Pending Cla CX Survey-Claimants with a Pending Claim 5-1-2023.docx	Form
1225-0093 - A11 Section 280 Clearance - Black Lung-Pending Claims 5.1.docx 1225-0093 - OWCP Black Lung - Pending Claims	IC Document
1225-0093 - A11 Section 280 Clearance - Black Lung-Pending Claims 5.1.docx 1225-0093 - OWCP Black Lung - Pending Claims	IC Document

IC Title:

DOL OWCP Black Lung - Claimants with Pending Claim

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	OWCP Black Lung CX Survey - Claimants with a Pending Claim	CX Survey-Claimants with a Pending Claim 5-1-2023.docx		No		Paper Only
Instruction			Black Lung Survey- Pending Claim - Instructions Updated 5-1-2023 (002).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
1225-0093 - OWCP Black Lung - Pending Claims	1225-0093 - A11 Section 280 Clearance - Black Lung-Pending Claims 5.1.docx	05/01/2023

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