Supporting Statement Voluntary Demographic DCMWC_MN_NMH-MM-12-01-23

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

OMB Control Number 1240-0NEW

OMB Expiration Date: XX/XX/XXXX

SUPPORTING STATEMENT FOR

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

OMB CONTROL NO. 1240-0NEW

The U.S. Department of Labor, Office of Workers’ Compensation Programs, Division of Coal Mine Workers’ Compensation, proposes a new information collection request (ICR), Voluntary Demographic Survey for OWCP Claimants.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

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 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.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The Voluntary Demographic Form is for claimants who have filed a claim for benefits with OWCP’s Division of Coal Miner Workers’ Compensation. It will be separated from the application and annual review forms upon receipt at the central mailroom. It will be maintained in a special queue that will only be available for review by the AI system; claims-processing staff will not have access to this data. Collection of demographic information will enable us to identify potential needs and provide better services to our underserved claimant population.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology (e.g., permitting electronic submission of responses) and the basis for the decision to adopt this means of collection. Also, describe any consideration of using information technology to reduce burden.

Upon approval of the Voluntary Demographic Form, DCMWC plans to send out this form to new claimants with the application forms (CM-911 and CM-912), during the initial development phase of their claim. For current beneficiaries, the form will be sent out with the Report of Changes that May Affect Your Black Lung Benefits, forms (CM-929 and CM-929P), for one year. Once a year goes by, this form will only be requested with our application forms (CM-911 and CM-912). OWCP determined that the form should not be made available on the Internet because it will be initiated by the DCMWC claims staff 100% of the time. It is estimated that 34% of these forms will be submitted electronically. The form can also be completed by hand and mailed or submitted online through the COAL Mine Portal at https://eclaimant.dol.gov/portal/?program_name=BL.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

There is no similar information available.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection does not have a significant economic impact on a substantial number of small entities.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

If this information is not collected, the program would have limited information with which to strengthen our customer experience and advance equity for injured and ill workers.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary, trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting public comment was published on August 08, 2023 (88 FR 53525). One anonymous comment was received in support of the proposed form. The comment does not affect the cost or the burden hours of this collection.

9. Explain any decision to provide any payments or gifts to respondents, other than remuneration of contractors or grantees.

Respondents do not receive any gifts or payments to furnish the requested information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

These forms will be separated at the central mailroom and unavailable to claims-processing staff. Since the completed forms are maintained in a special queue associated with the claimant’s case file Case ID, the information collected is covered by the Privacy Act System of Records, DOL/OWCP-2, published at 81 Fed. Reg. 25765, 25858 (April 29, 2016), or as updated and republished. The Privacy Act notice on the forms let users know under what circumstances information may be released.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

The voluntary demographic collection includes questions of a sensitive nature. The demographic questions asked are the minimum that can be asked when collecting demographic data based on the following Recommendations on the Best Practices for the Collection of Sexual Orientation and Gender Identity Data on Federal Statistical Surveys and Initial Proposals For Updating OMB’s Race and Ethnicity Statistical Standards. This form is completely voluntary, but it will provide those claimants who wish to share their information a chance to do so. Collecting demographic information will better inform the Black Lung Program of whom we are servicing and help us improve our customer service, gearing translation and outreach to all claimants.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.¹

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

The following information is estimated based on the number of respondents for ICR numbers 1240-0038 Miner’s Claim for Benefits under the Black Lung Benefits Act and Employment History (CM-911), 1240-0028 Report of Changes that May Affect Your Black Lung Benefits (CM-929 and CM-929P), and 1240-0027 Survivor’s Form for Benefits under the Black Lung Benefits Act (CM-912). We acknowledge our assumption that 100% of claimants will respond to a voluntary demographic survey may overestimate the number of responses and burden associated with this collection; however, we use these data as a point of reference, since we do not have historical data for this new collection.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Monetized Value of Respondent Time
CM-911	5,010	1	5,010	0.0833	417 (rounded)	$7.25	$3,023.25
CM-912	1,067	1	1,067	0.0833	89 (rounded)	$5.86	$521.54
CM-929 & CM-929P	12,000 (combined)	1	12,000	0.0833	1,000 (rounded)	$7.25	$7,250.00
Totals	18,077		18,077		1,506		$10,794.79

CM-911

The estimated burden of capturing demographic information through the miner’s application process is approximately 418 hours. This burden is based on the submission of 5,010 CM-911’s with 5 minutes (0.0833 hour) to read and complete the supplemental demographic form.

0.0833 hour/form x 5,010 forms == 417.33 or 417 (rounded down) total burden hours.

For the burden cost to the applicant, we use the 2022/2023 Federal minimum wage of $7.25 per hour. https://www.minimum-wage.org/federal

417 burden hours x $7.25 per hour = $3,023.25

CM-912

The estimated burden of capturing demographic information through the survivor’s application process is approximately 89 hours. This burden is based on the submission of 1,067 CM-912’s with 5 minutes to read and complete the supplemental demographic form.

0.0833 hour/form x 1,067 forms == 88.77 or 89 (rounded up) total burden hours.

The cost is computed by using the hourly Black Lung beneficiary benefit rate of $5.86. ($860 monthly × 12 months = $10,320 annually; $10,320 annually ÷ 220 OPM annual workdays = $46.90 daily; $46.90 daily ÷ 8 work-hours daily = $5.86 hourly.)

$5.86 hourly × 142 burden hours = $832.12, or $832 (rounded down) burden cost of time.

https://www.ecfr.gov/cgi-bin/textidx?SID=29bc2eece4de07711e99fe94392c8bf3&mc=true&node=se20.4.725_1520&rgn=div8 and https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/23Tables/html/RUS.aspx

CM-929 & CM-929P

These forms are sent to beneficiaries or their representative payees on a yearly basis to certify and/or correct information reflected in DCMWC’s files. The estimated burden of capturing demographic information through these annual forms is approximately 1,000 hours. This burden is based on submission of 12,000 CM-929 & CM-929P forms with 5 minutes to read and complete the supplemental demographic form.

0.0833 hour/form x 12,000 forms = 999.6 or 1,000 (rounded up) total burden hours.

For the burden cost to the beneficiary or representative, we use the wage rate of 2022/2023 Federal minimum wage of $7.25 per hour. https://www.dol.gov/whd/minimumwage.htm,

1,000 burden hours x $7.25 per hour = $7,250.00

Total Time Burden & Monetized Cost of Time:

1,506 Hours (417 _CM-911 + 89 _CM-912 + 1,000 _{CM-929 & CM-929P} = 1,506 hours)

$10,794.79 ($3,0234.25 _CM-911 + $521.24 _CM-912 + $7,250 _{CM-929 & CM-929P} = $10,794.79)

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and start up cost component (annualized over its expected useful life); and (b) a

total operation, maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government or (4) as part of customary and usual business or private practices.

The following information is based on the number of respondents for ICR numbers 1240-0038, 1240-0028, and 1240-0027. We acknowledge our assumption that 100% of claimants will respond to a voluntary demographic survey may overestimate the number of responses and burden associated with this collection; however, we use these data as points of reference since we do not have historical data for this new collection.

CM-911

Respondent’s cost to mail each response is estimated at 69¢ (66¢ stamp plus 03¢ for the envelope). Responses mailed will have a respondent cost of $3,456.90 (5,010 x 69¢ = $3,456.90).

Of the 5,010 responses that will be sent to DCMWC, it is estimated that 30% will be submitted electronically through the COAL Mine Portal (5,010 x 30% = 1,503). The estimated savings of the forms submitted through the COAL mine portal is $1,037.07 (1,503 x 69¢=$1,037.07). The remaining 3,507 responses will be mailed to DCMWC with a respondent cost of $2,419.83 (3,507 x 69¢ = $2,419.83).

Therefore, the total respondent cost is $ 2,420.00 (rounded up) ($3,456.90 - $1,037.07=$2,419.83).

There are no other known operating or maintenance costs associated with this collection.

CM-912

Respondent’s cost to mail each response is estimated at ¢69 (¢66 stamp plus ¢ 03 for the envelope) for postage and envelope. 1,067 x .69 = $736.23.

Of the 1,067 responses that will be sent to DCMWC, it is estimated that 4% will be submitted electronically through the COAL Mine Portal (1,067 x 4% =43 (rounded up). The estimated savings of the forms submitted through the COAL mine portal is $29.67 (43 x ¢69 = $29.67). The remaining 1,024 responses will be mailed to DCMWC with a respondent cost of $706.56 (1,024 x. ¢69 = $706.56).

Therefore, the total respondent cost is $ 707.00 (rounded up) ($736.23-$29.67=$706.56).

There are no other known operating or maintenance costs associated with this collection.

CM-929 and CM-929P

There are no technological or system costs associated with the collection of this information.

This form is sent with a Business Reply Envelope.

Total

Annual burden cost is $3,127 ($2,420 _CM-911 + $707 _CM-912 + $0 _{CM-929 & CM-929P} = $3,127).

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

The following information is a potential estimate based on ICR numbers 1240-0038, 1240-0028 and 1240-0027. The program experts used these data as points of reference since we do not have historical data for this new collection.

There would be no additional cost to the Federal Government by including this form with the application forms (CM-911 and CM-912) and the “Report of Changes That May Affect Your Black Lung Benefits” forms (CM-929 and CM-929P).

For the 18,077 responses DCMWC expects to receive, 100% will be reviewed by the Artificial Intelligence (AI) system. The cost to the Federal Government is estimated to be $5,000 for the development cost during the implementation phase, and $1,200 or less for the annual maintenance cost thereafter.

15. Explain the reasons for any program changes or adjustments.

There are no changes since this is a new collection.

16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This ICR does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement.

There are no exceptions to the certification statement.

B. COLLECTIONS OF INFORMATON EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in these collections of information.

1 Indicate the retention period for any recordkeeping requirements that pertain to the ICR.

10