Information Collection

1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History

IC 13681 under ICR 202401-1240-012 · OMB 1240-0038.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits CM-911 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits CM-911 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-911a Employment History CM-911a Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-911a Employment History CM-911a Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	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 725.304(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-911	Minerâs Claim for Benefits Under The Black Lung Benefits Act	CM-911 Form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-911a	Employment History	CM-911a Form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

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

Number of Respondents: 5,010	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10,020	10,020
Annual IC Time Burden (Hours)	8,768	8,768
Annual IC Cost Burden (Dollars)	2,420	2,420

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.