Voluntary Demographic Survey for Office of Workers’ Compensation Programs (OWCP) Claimants

Forms and Documents

Document Name	Status
Form CM-411 Voluntary Demographic Survey for Office of Workers' Compensation Programs (OWCP) Claimants Form	New
Supporting Statement Voluntary Demographic DCMWC_MN_NMH-MM-12-01-23.docx Supporting Statement A	2023-12-20

IC Document Collections

IC ID	Document Title	Status
263928	Voluntary Demographic Survey for Office of Workers' Compensation Programs (OWCP) Claimants Form	New

ICR Details

OMB Control No:	ICR Reference No: 202312-1240-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Voluntary Demographic Survey for Office of Workers’ Compensation Programs (OWCP) Claimants
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/20/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	18,077	0
Time Burden (Hours)	1,506	0
Cost Burden (Dollars)	3,127	0

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Abstract: Voluntary Demographic Form Historically, the Black Lung Program application forms and other claims processing forms have not collected demographic information. The use of this voluntary demographic form will help identify underserved communities and guide language and outreach strategies, thereby strengthening the customer service experience. Collecting and analyzing demographic data aligns with the following executive orders Executive Orders: Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, signed by President Biden in January 2021; Executive Order 14075, Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals, also signed by President Biden in January 2021; Executive Order 14031, Advancing Equity, Justice, and Opportunity for Asian Americans, Native Hawaiians, and Pacific Islanders, signed in May 2021; and Executive Order 14058, Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government, signed in December 2021.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 53525	08/08/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 88126	12/20/2023
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Voluntary Demographic Survey for Office of Workers' Compensation Programs (OWCP) Claimants	CM-411	Voluntary Demographic Survey for Office of Workers’ Compensation Programs (OWCP) Claimants

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ICR Summary of Burden

	Total Request	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	18,077	0	0	18,077	0	0
Annual Time Burden (Hours)	1,506	0	0	1,506	0	0
Annual Cost Burden (Dollars)	3,127	0	0	3,127	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There are no changes since this is a new collection.

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Annual Cost to Federal Government: $1,200

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]? Yes

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

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Common Form ICR:  No

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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: 12/20/2023

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