Disclosure of Medical Evidence

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
WCPO-2025-0002-DRAFT-_Comment_Anonymous-1240-0054.html	Public Comments	Uploaded 2025-05-04	Repair queued
1240-0054 Supporting Statement 2025-Final.docx	Supporting Statement A	Uploaded 2025-05-20	Repair queued
1240-0054 Supporting Statement 2025-Final.docx	Supporting Statement A	Uploaded 2025-05-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216185	Disclosure of Medical Evidence		Modified

ICR Details

OMB Control No: 1240-0054	ICR Reference No: 202502-1240-006
Status: Active	Previous ICR Reference No: 202201-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Disclosure of Medical Evidence
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/11/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/04/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved	08/31/2025
Responses	6,797	0	6,105
Time Burden (Hours)	1,135	0	1,018
Cost Burden (Dollars)	16,041	0	10,745

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Abstract: The Black Lung Benefits Act (BLBA), 30 U.S.C. 901 et seq., may require parties to exchange all medical information about the miner they develop in connection with a claim for benefits, including information parties do not intent to submit as evidence in the claim. BLBA regulations help protect a miner's health, assist unrepresented parties, and promote accurate benefit determinations. The potential parties to a BLBA claim include the benefits claimant, the responsible coal mine operator and its insurance carrier, and the Director of OWCP. Under BLBA, a party of a party's agent who receives medical information about the miner must send a copy to all other parties within 30 days after receipt or, if a hearing before an administrative law judge has already been scheduled, at least 20 days before the hearing. The exchanged information is entered into the record of the claim only if a party submits it into evidence.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
   US Code: 30 USC 936 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:
	90 FR 11191	03/04/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 23714	06/04/2025
Did the Agency receive public comments on this ICR? No

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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
Disclosure of Medical Evidence

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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	6,797	6,105	0	692	0	0
Annual Time Burden (Hours)	1,135	1,018	0	117	0	0
Annual Cost Burden (Dollars)	16,041	10,745	0	5,296	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Respondents: The number of respondents increased from 6,105 to 6,797. The number of respondents increased due to an increase of the number of black lung cases adjudicated by OWCP and the Office of Administrative Law Judges. The following also increased due to an increased in number of respondents. Responses: Responses have increased from 6,105 to 6,797. Burden Hours: Burden hours have increased from 1,018 to 1,135. Costs: Annual burden costs have increased from $10,745 to $16,041 due to the increase in postage and increased number of responses. Also, the average number of pages submitted for disclosure purposes only increased from 3 pages to 4 pages.

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Annual Cost to Federal Government: $16,041

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: 06/04/2025

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