Supporting Statement 1240-0034-12-11.24

Authorization for Release of Medical Information (Black Lung Benefits) OMB Control Number 1240-0034

OMB Expiration Date: 03/31/2025

SUPPORTING STATEMENT FOR

Authorization for Release of Medical Information Black Lung Benefits

OMB CONTROL NO. 1240-0034

This ICR seeks to revise this information collection.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

Claims under the Black Lung Benefits Act (BLBA), 30 USC 901 et seq., generally require consideration of medical information about the miner. When a claimant wants existing medical data to be considered, an executed CM-936 form authorizes physicians, hospitals, medical facilities or organizations, and the National Institute of Occupational Safety and Health to release medical information about the miner to the Office of Workers’ Compensation Programs (OWCP). The BLBA, 30 USC 923(b), and the implementing regulations, 20 CFR 725.405, authorize this information collection because they require that all relevant medical evidence be considered in deciding a claimant's eligibility for benefits.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The claimant uses the CM-936 form to authorize physicians, hospitals, medical facilities or organizations, and the National Institute of Occupational Safety and Health to release medical information about the miner to OWCP. The form may be completed by the claimant or claims staff. If the claims staff completes the form from information already in the claim file, the claimant must verify and sign the authorization.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology (e.g., permitting electronic submission of responses) and the basis for the decision to adopt this means of collection. Also, describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act (GPEA), Form CM-936 is electronically interactive and is posted on the internet at

https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black.

The form may be completed online, printed, and mailed; or, it may be printed, completed by hand, and mailed. The completed form may also be submitted electronically through the COAL Mine Portal at https://coalmine.dol.gov.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

The Federal Black Lung Program has no other medical release form. Other programs have medical release forms; however, they are program-specific for covered occupational illnesses and do not specifically request medical evidence related to the adjudication of black lung claims. There is no similar information available.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of this information does not impose a significant impact on small entities.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

If this form were not used, the adjudication of the black lung claim would be incomplete, because pertinent medical data would not be available for consideration.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary, trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting public comment was published on September 6^th, 2024 (89 FR 72900). No comments were received.

DCMWC consulted with two internal representatives and a group of external representatives during the WV outreach event regarding this information collection request. DCMWC asked these contacts for feedback on burden estimates.

DCMWC Internal representatives recommended modifications to the CM 936 to expand its applicability. The revised form now accommodated medical releases from any type of medical facility, not just hospitals. Consequently, all references in block 8 to “Hospitals” or “hospitalization” have been updated to “Facility or Clinic”, encompassing to all doctor’s offices, medical clinics, urgent care facilities, and hospitals. Additionally, DCMWC suggested updates to the initial blocks to more accurately reflect the form’s use, specifically recognizing that the person completing the form may not be the miner or claimant. The form has also been modified to capture information for multiple medical facilities, with Blocks #13 through #15 designed to collect the same information for up to four different providers

DCMWC has revised its CM-936 form to adopt the above recommendations. These changes ensure that medical information can be requested from any type of medical provider and from multiple medical providers utilizing the same signature authority.

The current version of the CM-936 requested information from a single medical provider. The revised form, however, accommodates information from up to four providers. As a result, DCMWC anticipates that completing the form may take up to four times longer than before. Consequently, the Public Burdern Statement has been adjusted to reflect this increase, with the estimated completion time now averaging 20 minutes, up from the previous average of 5 minutes. The individuals/organizations consulted about the information collection are listed in the table below.

The group of external stakeholders did not have additional comments regarding the proposed burden estimates. DCMWC is proceeding with the initial estimates published in the 60-day notice.

The individuals/organizations consulted about the information collection are listed in the table below.

 

Table 1: List of Internal and External Representatives

 

Contact	Organization	Email	Phone
Danielle XXX	Claims Examiner/ Policy Analyst Branch of Policy Analysis and Program Standards	XXX	XXX
WV outreach event	Cabin Creek Health, Boone Memorial Black Lung Clinic and Preston-Taylor Community Health Centers, Inc.,	XXX	XXX
Saul XXX	Claims Examiner/ Policy Analyst Branch of Policy Analysis and Program Standards	XXX	XXX

9. Explain any decision to provide any payments or gifts to respondents, other than remuneration of contractors or grantees.

No payments or gifts are made to respondents to furnish the information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

Since the completed form is maintained in the beneficiary’s case file, the information collected is covered by the Privacy Act System of Records, DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25765, 25858, and 25866 (April 29, 2016), or as updated and republished.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This collection contains no questions of a sensitive nature.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Monetized Value of Respondent Time
CM-936	5,990	1	5,990	0.333	1,995 (rounded)	$7.25	$14,463.75

There are approximately 5,990 respondents annually. One form is sent to each respondent, who spends approximately 20 minutes to complete and submit the form. Thus, there is an annual burden of 1,995 hours (5,990 X 0.333 minutes = 1,994.67 hours rounded).

To estimate the annual cost of the burden hours to the CM-936 respondents, the Federal minimum wage of $7.25 per hour, has been applied. Verification was obtained from https://www.dol.gov/agencies/whd/mw-consolidated. Thus, the total annual cost to CM-936 respondents is $14,464 (rounded up) ($7.25 X 1995 burden hours).

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and start up cost component (annualized over its expected useful life); and (b) a

total operation, maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government or (4) as part of customary and usual business or private practices.

The federal government provides prepaid postage for the claimants to return the forms. As a result, there is no cost burden on respondents.

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

The estimated total cost to the Federal Government for the 5,990 forms is approximately $8,865.20, The cost is figured as follows:

1. Estimated mailing cost: $8,865.20 (¢.69 metered postage plus $.05 per envelope

=¢ .74) 5,990 forms x ¢ .74= $4,432.60 x 2= 8,865.20

15. Explain the reasons for any program changes or adjustments.

The estimated number of responses and respondent burden hours has increased due to an increased in the number of claims filed.

EXPLANATION OF CHANGE TOTALS

Respondents: The number of respondents increased from 5,000 to 5,990.

The following also increased due to an increased in number of respondents.

Responses: Responses have increased from 5,000 to 5,990.

Burden Hours: Burden hours have increased from 417 to 1,995. The current version of the CM-936 requested information from a single medical provider. The revised form, however, accommodates information from up to four providers. As a result, DCMWC anticipates that completing the form may take up to four times longer than before. Consequently, the Public Burdern Statement has been adjusted to reflect this increase, with the estimated completion time now averaging 20 minutes, up from the previous average of 5 minutes.

Costs: No other cost reported for this collection.

16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This ICR does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement.

There are no exceptions to the certification statement.

B. COLLECTIONS OF INFORMATON EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in this collection of information.

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