Application for Self-Insurance Under the Black Lung Benefits Act

Forms and Documents

Document Name	Status
Form CM-2017 Application for Self-Insurance Under the black Lung Benefits Act Form	Modified
8.19.24 Supporting Statement 1240-0057 - Final.docx Supporting Statement A	2024-08-19

IC Document Collections

IC ID	Document Title	Status
234819	Application for Self-Insurance Under the black Lung Benefits Act Form	Modified

ICR Details

OMB Control No: 1240-0057	ICR Reference No: 202404-1240-003
Status: Received in OIRA	Previous ICR Reference No: 202401-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Application for Self-Insurance Under the Black Lung Benefits Act
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/15/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2025
Responses	142	294
Time Burden (Hours)	246	261
Cost Burden (Dollars)	34,000	34,080

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Abstract: This information collection is essential to the mission of OWCP’s Division of Coal Mine Workers’ Compensation, which administers the Black Lung Benefits Act (BLBA), 30 U.S.C. 901 et seq. The statute grants the Department authority to authorize and regulate coal mine operators who wish to self-insure their BLBA liabilities. 30 U.S.C. 933. This information collection would provide OWCP with sufficient information to determine whether a coal mine operator should be (or continue to be) authorized to self-insure. The information would also allow OWCP to determine the security amount a coal mine operator must deposit to guarantee that it will be able to meet its BLBA liabilities.

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Authorizing Statute(s): US Code: 30 USC 933 Name of Law: Black Lung Benefits Act (BLBA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1240-AA16	Final or interim final rulemaking	89 FR 100304	12/12/2024

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Self-Insurance Under the black Lung Benefits Act	CM-2017, CM-2017b	Application or Renewal of Self-Insurance Authority ,   Report of Claims Information for Self-Insured Operators

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ICR Summary of Burden

	Total Request	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	142	294	0	-176	24	0
Annual Time Burden (Hours)	246	261	0	-63	48	0
Annual Cost Burden (Dollars)	34,000	34,080	0	-80	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: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: The final rule contains information collections within the meaning of the PRA, but these collections are not new. Aside from the removal of the collection associated with submitting form CM-2017a to OWCP, the requirements for completion of the forms and the information collected on the forms will not change if this proposed rule is adopted. Respondents: The estimated number of self-insured operators has increased from 49 to 61. The number of respondents increased due to increased number of estimated applications for self-insurance. Both the below estimated annualized responses and burden hours have decreased due to the removal of the CM-2017a form despite the increase in respondents. Responses: Responses have decreased from 294 to 122. Burden Hours: Burden hours have decreased from 261 to 244. Costs: Annual burden costs have decreased from $34,080 to $34,000 due to the removal of the associated mailing costs.

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Annual Cost to Federal Government: $15,695

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: 01/15/2025

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