Authorization for Release of Medical Information for Black Lung Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-936 Authorization For Release of Medical Information (Black Lung Benefits)	Form	Modified	Available
Form CM-936 Authorization for Release of Medical Information	Form	Modified	Repair queued
Supporting Statement - 1240-0034 OCIO -MM Comments 1.7.22 OCIO Response.docx	Supporting Statement A	Uploaded 2024-01-30	Available
Supporting Statement - 1240-0034 OCIO -MM Comments 1.7.22 OCIO Response.docx	Supporting Statement A	Uploaded 2024-01-30	Repair queued
Justification CM-936.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-30	Available
Justification CM-936.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-30	Repair queued
System of Record Notice-DOL OWCP-2.pdf	Supplementary Document	Uploaded 2018-09-27	Available
System of Record Notice-DOL OWCP-2.pdf	Supplementary Document	Uploaded 2018-09-27	Repair queued
725.405.pdf	Supplementary Document	Uploaded 2006-08-09	Available
725.405.pdf	Supplementary Document	Uploaded 2006-08-09	Repair queued
30 USC Sec. 902.pdf	Supplementary Document	Uploaded 2006-08-09	Available
30 USC Sec. 902.pdf	Supplementary Document	Uploaded 2006-08-09	Repair queued
30 USC Sec. 901.pdf	Supplementary Document	Uploaded 2006-08-09	Available
30 USC Sec. 901.pdf	Supplementary Document	Uploaded 2006-08-09	Repair queued
30 Chapter 22.pdf	Supplementary Document	Uploaded 2006-08-09	Available
30 Chapter 22.pdf	Supplementary Document	Uploaded 2006-08-09	Repair queued
DOL-ESA-30.pdf	Supplementary Document	Uploaded 2006-08-09	Available
DOL-ESA-30.pdf	Supplementary Document	Uploaded 2006-08-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13694	Authorization for Release of Medical Information	Form	Modified	Authorization For Release of Medical Information (Black Lung Benefits)
13694	Authorization for Release of Medical Information	Form	Modified

ICR Details

OMB Control No: 1240-0034	ICR Reference No: 202401-1240-009
Status: Historical Active	Previous ICR Reference No: 202111-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Authorization for Release of Medical Information for Black Lung Benefits
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/04/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/31/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2025	03/31/2025	03/31/2025
Responses	5,000	0	5,000
Time Burden (Hours)	417	0	417
Cost Burden (Dollars)	0	0	0

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Abstract: The CM-936 is used to obtain the black lung claimant's authorization for the Division of Coal Mine Workers' Compensation to request medical evidence in support of the black lung claim.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

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:
	86 FR 50909	09/13/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 3127	01/20/2022
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Authorization for Release of Medical Information	CM-936	Authorization For Release of Medical Information (Black Lung Benefits)

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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	5,000	5,000	0	0	0	0
Annual Time Burden (Hours)	417	417	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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:

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Annual Cost to Federal Government: $5,300

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

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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: 01/31/2024

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