Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

Claim Adjudication Process for the Alleged Presence of Pneumoconiosis

OMB: 1240-0023

IC ID: 13765

Documents and Forms

Document Name Document Type
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
CM-933 Radiologic Interpretation CM-933-Form Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-933 Radiologic Interpretation CM-933-Form Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-933b Radiologic Quality Rereading CM-933b Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-933b Radiologic Quality Rereading CM-933b Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-988 Medical History and Examination for Coal Mine Workers’ P CM-988 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-988 Medical History and Examination for Coal Mine Workers’ P CM-988 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-1159 Report of Arterial Blood Gas Study CM-1159 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-1159 Report of Arterial Blood Gas Study CM-1159 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-2907 Report of Ventilatory Study CM-2907 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-2907 Report of Ventilatory Study CM-2907 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 718.202 20 CFR 725.406 20 CFR 718.204 20 CFR 718.102-105

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-933	Radiologic Interpretation	CM-933-Form Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-933b	Radiologic Quality Rereading	CM-933b Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-988	Medical History and Examination for Coal Mine Workers’ Pneumoconiosis	CM-988 Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-1159	Report of Arterial Blood Gas Study	CM-1159 Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-2907	Report of Ventilatory Study	CM-2907 Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2 and DOL/OWCP-9	FR Citation: 67 FR 16869

Number of Respondents: 21,500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	21,500	21,500
Annual IC Time Burden (Hours)	5,232	5,232
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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