Information Collection Request
Authorization for Release of Medical Information for Black Lung Benefits
ICR 202401-1240-009 · OMB 1240-0034 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0034 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CM-936 Authorization for Release of Medical Information |
Form | Modified | Available |
| Form CM-936 Authorization for Release of Medical Information |
Form | Modified | Missing upstream |
 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
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 13694 |  Authorization for Release of Medical Information |
Form | Modified | |
| 13694 | Authorization for Release of Medical Information |
Form | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0034 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202111-1240-003 |
| Date Submitted to OIRA | 2024-01-31 |
| Requested Expiration Date | 1969-12-31 |