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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-911a Employment History	Form	Modified	Available
Form CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits Act	Form	Modified	Available
Form CM-911a Employment History	Form	Modified	Available
Form CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits Act	Form	Modified	Available
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Repair queued
Justification CM-911 & CM-911a Translated in Spanish.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-21	Available
Justification CM-911 & CM-911a Translated in Spanish.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-21	Repair queued
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx	Supporting Statement A	Uploaded 2024-01-30	Available
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx	Supporting Statement A	Uploaded 2024-01-30	Repair queued
Justification CM-911 & CM-911a.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-30	Available
Justification CM-911 & CM-911a.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-30	Repair queued
725.404.docx	Supplementary Document	Uploaded 2018-04-10	Available
725.404.docx	Supplementary Document	Uploaded 2018-04-10	Repair queued
System of Record Notice.pdf	Supplementary Document	Uploaded 2018-01-08	Available
System of Record Notice.pdf	Supplementary Document	Uploaded 2018-01-08	Repair queued
20CFR725.304 - Forms and initial processing.pdf	Supplementary Document	Uploaded 2014-08-08	Available
20CFR725.304 - Forms and initial processing.pdf	Supplementary Document	Uploaded 2014-08-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Employment History
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Miner’s Claim for Benefits Under The Black Lung Benefits Act
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Employment History
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Miner’s Claim for Benefits Under The Black Lung Benefits Act
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified

ICR Details

OMB Control No: 1240-0038	ICR Reference No: 202402-1240-002
Status: Active	Previous ICR Reference No: 202401-1240-012
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
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: 03/14/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/13/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2026	10/31/2026	10/31/2026
Responses	10,020	0	10,020
Time Burden (Hours)	8,768	0	8,768
Cost Burden (Dollars)	2,420	0	2,420

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Abstract: CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and this form is completed by all applicants, both miners and survivors.

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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:
	88 FR 38544	06/13/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 64929	09/20/2023
Did the Agency receive public comments on this ICR? Yes

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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
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	CM-911, CM-911a, CM-911, CM-911a	Miner’s Claim for Benefits Under The Black Lung Benefits Act ,   Employment History ,   Miner’s Claim for Benefits Under The Black Lung Benefits Act ,   Employment History

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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	10,020	10,020	0	0	0	0
Annual Time Burden (Hours)	8,768	8,768	0	0	0	0
Annual Cost Burden (Dollars)	2,420	2,420	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: $227,003

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: 03/13/2024

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