OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 13681 under ICR 202402-1240-002 · OMB 1240-0038.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.304(a)

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

Income Security General Retirement and Disability

DOL/OWCP-2  67 FR 16869

5,010 0
   
Individuals or Households
 
   30 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 10,020 0 0 0 0 10,020
Annual IC Time Burden (Hours) 8,768 0 0 0 0 8,768
Annual IC Cost Burden (Dollars) 2,420 0 0 0 0 2,420

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.