MINER’S CLAIM for BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-911 AND EMPLOYMENT HISTORY CM-911a

NON- SUBSTANTIVE CHANGE REQUEST FOR THE MINER’S CLAIM for BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-911 AND EMPLOYMENT HISTORY CM-911a

OMB CONTROL NO. 1240-0038 (January 2024)

DCMWC is requesting a non-substantive change to the recently approved collection of information contained in “Miner’s Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a” to update the URL of the coal mine portal and add our toll-free telephone number in the CM-911 and CM-911a Form.

DCMWC seeks to revise the recently approved CM-911 and CM-911a as follows:

TWO FILING OPTIONS:

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal:

https://coalmine.dol.gov

2. To file by mail submit completed form and accompanying documentation to:

U.S. Department of Labor OWCP/DCMWC

Central Mail Room

PO Box 8307

London, KY 40742-8307

For further information call TOLL FREE: 1-800-347-2502

This change request does not affect the burden hours. The burden hours remain the same.

The revised forms are attached to this change request.