Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a

ICR 202401-1240-012

OMB: 1240-0038

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0038 can be found here:

2024-03-13 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form	Modified
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form	Modified
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx Supporting Statement A	2024-01-30
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx Supporting Statement A	2024-01-30
Justification CM-911 & CM-911a.docx Justification for No Material/Nonsubstantive Change	2024-01-30
Justification CM-911 & CM-911a.docx Justification for No Material/Nonsubstantive Change	2024-01-30
725.404.docx Supplementary Document	2018-04-10
725.404.docx Supplementary Document	2018-04-10
System of Record Notice.pdf Supplementary Document	2018-01-08
System of Record Notice.pdf Supplementary Document	2018-01-08
20CFR725.304 - Forms and initial processing.pdf Supplementary Document	2014-08-08
20CFR725.304 - Forms and initial processing.pdf Supplementary Document	2014-08-08

IC Document Collections

IC ID	Document Title	Status
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form	Modified
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form	Modified

ICR Details

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