Information Collection

OWCP Black Lung Worker's Compensation Program End-to-End Experience Customer Interviews

IC 256615 under ICR 202504-1225-002 · OMB 1225-0093.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1225-0093 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Claimant Interview Guide- Black Lung.docx	Instruction
Claimant Interview Guide- Black Lung.docx	Instruction
Consent Form_ Black Lung.docx Black Lung Consent Form	IC Document
Consent Form_ Black Lung.docx Black Lung Consent Form	IC Document
ICR DOL OWCP BlackLung Program Supporting Statement.docx 1225-0093 Supporting Statement - Black Lung End-to-End Experience Interviews	IC Document
ICR DOL OWCP BlackLung Program Supporting Statement.docx 1225-0093 Supporting Statement - Black Lung End-to-End Experience Interviews	IC Document

IC Title:

OWCP Black Lung Worker's Compensation Program End-to-End Experience Customer Interviews

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	16	16
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Black Lung Consent Form		10/26/2022
1225-0093 Supporting Statement - Black Lung End-to-End Experience Interviews		10/26/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].