Request for State or Federal Workers' Compensation Information

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-905 Request for State or Federal Compensation Information	Form	Modified	Available
1240-0032 Supporting Statement 2026.docx	Supporting Statement A	Uploaded 2026-03-11	Available
System of Record Notice-DOL OWCP-2.pdf	Supplementary Document	Uploaded 2019-11-14	Available
20 CFR 725 535.pdf	Supplementary Document	Uploaded 2013-06-25	Available
30 USC 924.pdf	Supplementary Document	Uploaded 2013-06-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13703	Request for State or Federal Workers' Compensation Information	Form	Modified	Request for State or Federal Compensation Information
13703	Request for State or Federal Workers' Compensation Information	Form	Modified

ICR Details

OMB Control No: 1240-0032	ICR Reference No: 202601-1240-005
Status: Received in OIRA	Previous ICR Reference No: 202304-1240-008
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for State or Federal Workers' Compensation Information
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/11/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2026
Responses	3,980	4,155
Time Burden (Hours)	995	1,039
Cost Burden (Dollars)	2,973	2,356

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Abstract: The OWCP Division of Coal Mine Workers’ Compensation must collect information regarding the status of any worker's compensation inquiry for Federal or State claims regarding benefits received attributable to black lung disability. The OWCP Form CM-905 requests the amount of those workers' compensation benefits and is submitted from Federal or state agencies when the beneficiary has filed a claim for workers' compensation benefits due to pneumoconiosis or is receiving benefits that may need to be offset.

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Authorizing Statute(s): US Code: 30 USC 901 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 61420	12/31/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 11991	03/11/2026
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
Request for State or Federal Workers' Compensation Information	CM-905	Request for State or Federal Compensation Information

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ICR Summary of Burden

table that charts list 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	3,980	4,155	0	0	-175	0
Annual Time Burden (Hours)	995	1,039	0	0	-44	0
Annual Cost Burden (Dollars)	2,973	2,356	0	0	617	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: No

Burden Reduction Due to:

Short Statement: Respondents: The number of respondents decreased from 4,155 to 3,980. The number of respondents decreased due to a decrease in forms processed. The following also decreased due to a decrease in number of forms received/responses. Responses: Responses have decreased from 4,155 to 3,980. Burden Hours: Burden hours have decreased from 1,039 to 995. Costs: Annual burden costs have increased from $2,356 to $2,973 due to postage rate increase.

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Annual Cost to Federal Government: $52,238

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.     No

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.     No

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: 03/11/2026

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