March 6, 2007

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SUPPORTING STATEMENT FOR
 
Survivor's Form for Benefits under the Black Lung Benefits Act

OMB CONTROL NO. 1240-0027

This ICR seeks an extension to the currently approved version. 

    A. 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.

This collection of information is required to administer the benefit payment provisions of the Black Lung Benefits Act for survivors of deceased miners.  Completion of this form constitutes the application for benefits by survivors and assists in determining the survivor's entitlement to benefits.  This form is authorized by the Black Lung Benefits Act (30 USC 901-945) and its implementing regulations (20 CFR 725.304(a)).

 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.

Survivor applications are used by Division of Coal Mine Workers' Compensation (DCMWC) claims staff to determine a survivor's eligibility for benefits.  The claims staff reviews the information submitted with the survivor's application along with any pertinent evidence already in the file and, as necessary, informs the claimant of any additional information needed to meet the eligibility requirements to adjudicate the claim.  The eligibility requirements are given in 20 CFR 725.212-225.

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.

The form is available for downloading at http://www.dol.gov/owcp/regs/compliance/cm-912.pdf. The form can be printed, completed by hand, signed, and mailed or it can be completed online, signed, and submitted through the COAL Mine Portal at https://coalmine.dol.gov/. It is estimated that 10% of the forms would be submitted utilizing this method. This form is also available in Spanish and large print. 
 

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.

There is no similar approved form used by DCMWC.  Since the information collected is specific to Federal Black Lung beneficiary survivors, no other agency gathers this information.

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

Collection of this information does not involve small businesses or other 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.

This is a one-time collection from applicants; if the collection were less frequent, eligible survivors would not be able to exercise their right to apply for benefits under the Black Lung Benefits Act.

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 conducting 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 04/10/2026. (91FR 18488).  No comments were received.

DCMWC consulted with two internal and one external representative regarding this information collection request. DCMWC asked these contacts for feedback on burden estimates. None of the three representatives had any changes or comments on the estimated burden, so 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
Natalia XXX
Management and Program Analyst Branch of Fiscal Operations & Technical Support 
XXX
XXX
Kathy XXX
Holliday Law Office 
Claimant Representative 
XXX
XXX
Marcela 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.

Respondents do not receive any gifts or payments to furnish the requested information.

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

The information collected is covered by two Privacy Act System of Records, DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 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.

There are no questions of a sensitive nature on this form.

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.1

    • 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
(Rounded)
CM-912


1,080


1


1,080


0.133


144


$5.34


$769

The burden estimate for the CM-912 is based upon approximately 1,080 forms received yearly by DCMWC district offices.  A survivor needs to fill out an application only once. It takes approximately 8 minutes per response, for a total annual burden of 144 hours.

(1,080 forms x 8 min= 8,640 min/60 = 144 hours 

The estimated total cost to respondents for the burden hours is approximately $769.00.  The cost is computed by using the hourly Black Lung beneficiary benefit rate of $5.34.

To calculate “basic rate”
 https://www.ecfr.gov/cgi-bin/textidx?SID=29bc2eece4de07711e99fe94392c8bf3&mc=true&node=se20.4.725_1520&rgn=div8 and https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/26Tables/html/RUS.aspx 

GS2 Step one yearly pay rate: $29,725; to calculate the monthly pay rate: $29,725 ÷12=$2,477. The regulations indicate that the “basic rate” is equal to 371/2 percent of the monthly pay rate, $929(rounded up) ($2,477÷8=$309.625. $309.625 ×3+$928.875) 

To calculate Hourly Wage Rate:

$929 monthly × 12 months = $11,148 annually; $11,148 annually ÷ 260.875 OPM annual workdays = $42.73 daily; $42.73 daily ÷ 8 workhours daily = $5.34 hourly.  


Monetized Value of Respondent Time:

$5.34 hourly × 144 burden hours = $768.96 ($769.00 rounded up).

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.

Respondent’s cost to mail each response is estimated at ¢83 (¢78 stamp plus ¢05 for the envelope) for postage and envelope. 1,080 x ¢83 = $896.40.  This would be the total cost if we did not have any electronic submissions. 

However, of the 1,080 responses that will be sent to DCMWC, it is estimated that 10% (.10) or 108 responses will be submitted electronically through the COAL Mine Portal (1,080 x .10 = 108). The estimated savings of the forms submitted through the COAL mine portal is $89.64 (108 x ¢83 = $89.64). The remaining 972 responses will be mailed to DCMWC with a respondent cost of $ 806.76 (972 x 83¢ =$806.76).

Therefore, the total respondent cost is $807.00 (rounded up) ($896.40 - $89.64 = $806.76). 

There are no other known operating or maintenance costs associated with this collection.

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 this information collection is approximately $13,978.00 ($13,977.90 rounded up).  The cost is computed as follows:

 a. Estimated mailing cost: $853.20 (¢.74 metered postage plus ¢.05 per envelope = ¢0.79) 1,080 forms x ¢.79 = $853.20
 
	
b.	Estimated processing cost: $13,124.70. The claims examiner (GS 12/5) spends about 15 minutes evaluating each form. The 2026 hourly rate for a GS 12 step 5 is $48.61 https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/26Tables/html/RUS_h.aspx

1,080 x 0.25hours= 270 hours x $48.61= $13,124.70

	
$853.20 mailing costs + $13,124.70 processing costs = $13,977.90 total costs.

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

EXPLANATION OF CHANGE TOTALS

Respondents: The number of respondents increased from 1,067 to 1,080. The number of respondents increased due to an increase in claims filed. 

The following estimates also increased due to an increase in number of forms received/responses.

Responses: Responses have increased from 1,067 to 1,080.

Burden Hours: Burden hours have increased from 142 to 144.

Costs: Annual burden costs have increased from $707.00 to $807.00.

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 these collections of information.