Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-911a Employment History	Form	Modified	Available
Form CM-911 Miner’s Claim for Benefits Under the Black Lung Benefits Act CM-911	Form	Modified	Available
SS-1240-0038 CM-911 CM-911a Final.docx	Supporting Statement A	Uploaded 2026-06-17	Available
725.404.docx	Supplementary Document	Uploaded 2018-04-10	Available
System of Record Notice.pdf	Supplementary Document	Uploaded 2018-01-08	Available
20CFR725.304 - Forms and initial processing.pdf	Supplementary Document	Uploaded 2014-08-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Employment History
13681	1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form	Modified	Miner’s Claim for Benefits Under the Black Lung Benefits Act CM-911

ICR Details

OMB Control No: 1240-0038	ICR Reference No: 202603-1240-005
Status: Received in OIRA	Previous ICR Reference No: 202402-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/29/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	10,800	10,020
Time Burden (Hours)	9,450	8,768
Cost Burden (Dollars)	3,137	2,420

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Abstract: CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and these forms must be completed by all applicants.

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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:
	91 FR 20706	04/17/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 61452	09/29/2026
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
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	CM-911, CM-911a	Miner’s Claim for Benefits Under the Black Lung Benefits Act CM-911 ,   Employment History

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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	10,800	10,020	0	0	780	0
Annual Time Burden (Hours)	9,450	8,768	0	0	682	0
Annual Cost Burden (Dollars)	3,137	2,420	0	0	717	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: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents increased from 5,010 to 5,400. The number of respondents increased due to an increase in claims filed. Responses: Responses have increased from 10,020 to 10,800 due to an increase in number of forms received/responses. Burden Hours: Burden hours have increased from 8,768 to 9,450 due to an increase in number of forms received/responses. Costs: Annual burden costs have increased from $2,420 to $3,137 due to an increase in postage. Other changes not affecting burden estimates: It is the program’s discretion to make a few changes to the CM-911a necessary to obtain the specific mine site the miner worked at. Question #10 a and question #16.

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Annual Cost to Federal Government: $264,627

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: 09/29/2026

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