March 6, 2007

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SUPPORTING STATEMENT FOR
 Miner’s Claim for Benefits under the Black Lung Benefits Act CM-911 and Employment History CM-911a

OMB CONTROL NO. 1240-0038 

This ICR seeks a revision to the currently approved version. The changes made to the CM-911a Employment History are minimal and do not change the time burden estimates. 


    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.

CM‑911 

The Black Lung Benefits Act (BLBA), 30 USC 901 et seq., provides monthly disability benefits to coal miners who are totally disabled due to pneumoconiosis (black lung disease) and to certain survivors of miners. Miners entitled to benefits also receive medical benefits for treatment related to their pneumoconiosis and resulting disability. 

A miner who applies for black lung benefits must complete the CM‑911 (Miner’s Claim for Benefits under the Black Lung Benefits Act).  The completed form gives basic identifying information about the applicant and is the beginning of the development of the black lung claim. Regulation 20 CFR 725.304(a) authorizes this information collection.  

CM‑911a

An applicant filing for black lung benefits must complete a CM‑911a (Employment History) at the same time the black lung application form is submitted.  This form provides a complete history of the miner’s employment and helps to establish whether the individual currently or formerly worked in the Nation’s coal mines and how long that employment lasted.  Regulation 20 CFR 725.404(a) authorizes this information collection.


 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.

CM‑911

Upon completion by the applicant and receipt of the CM‑911 by the Black Lung District Office, the claims staff reviews the information and begins the verification process of each item on the application.  For example, the claims staff requests copies of the birth and marriage records to establish dependency and to help determine the potential amount of benefits to which the miner would be entitled.  Upon receipt and verification of all items requested, the claims staff can determine if the applicant meets the statutory criteria for an award of benefits.  If this information were not collected and the miner’s signature were not obtained on the CM‑911, the requirements of the Black Lung Benefits Act would not be met.

CM‑911a

Once the CM‑911a is completed and received in the black lung office, the claims staff reviews and verifies the information to determine the existence and length of coal mine employment.  Other types of employment are also reviewed to help establish total disability due to coal mine employment. Proof of coal mine employment and its length are critical to establishing a causal relationship between a miner’s employment and total disability due to pneumoconiosis for entitlement purposes.  If this information were not gathered, neither coal mine employment, nor the length of that employment, could be established.



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 for adopting this means of collection.  Also, describe any consideration of using information technology to reduce burden.

Both forms are available for downloading at http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm.  These forms are also available in Spanish, Navajo/Dine bizaad and large print. 
 
The forms can be printed, completed by hand, signed, and mailed or they can be completed online, signed, and submitted through the COAL Mine Portal at https://coalmine.dol.gov/. It is estimated that 30% of the forms would be submitted utilizing this method.   

Each form requires the claimant’s signature and also provides space for the signatures of two witnesses if the claimant is unable to sign their name.  All signatures may be affixed electronically.  In cases where a claimant is unable to sign their name, two different and independently obtained digital signatures are required to submit such a form on-line.  In order to keep claim information confidential, the Department of Labor’s website does not permit the forwarding or submission of on-line forms to any place other than the Department’s designated electronic mailbox.  This prevents the claimant from forwarding the form to the witness after both had received their digital signature verification keys.

 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 information available.

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

This information is provided by individuals; thus, its collection does not impact 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 information is collected only at the time of application.  If it were collected less frequently, this information would not be available for case adjudication.

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 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 04/17/2026. (91 FR 20706).  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.

Since the completed forms are maintained in the claimant’s case file, the information collected is covered by the Privacy Act System of Records, DOL/OWCP-2, published at 81 Fed. Reg. 25765, 25858 (April 29, 2016), or as updated and republished. The Privacy Act notice on the forms lets users know under what circumstances information may be released.


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.

This collection contains no questions of a sensitive nature.


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.

    • 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 14.




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
Total Burden Cost
CM-911
5,400
1
5,400
.75
4,050

$7.25
$29,362.50

CM-911a
5,400
1
5,400
1
5,400 
$7.25
$39,150.00
Unduplicated Total
5,400
2
10,800

9,450

$68,512.50

CM‑911

The estimated burden of this information collection is approximately 4,050 hours.  This burden is based on a submission of 5,400 CM‑911's with 45 minutes (0.75 hour) to read and complete the form.  The Black Lung Offices supply the form and help the claimants complete the form.

0.75-hour x 5,400 forms = 4,050 burden hours.

For the burden cost to the applicant, we use the 2023/2024 Federal minimum wage of $7.25 per hour.  https://www.minimum-wage.org/federal 

4,050 burden hours x $7.25 per hour = $29,362.50

CM‑911a

The estimated burden of this information collection is approximately 5,400 hours.  This burden is based on a submission of 5,400 CM‑911a Forms with 1 hour to read and complete the form.  The Black Lung Offices supply the form and help the claimants complete the form. 

1 hour x 5,400 forms = 5,400 total burden hours.

For the burden cost to the applicant, we use the 2023/2024 Federal minimum wage of $7.25 per hour.  https://www.minimum-wage.org/federal 

5,400 burden hours x $7.25 per hour = $39,150.00

Total Time Burden:
5,400 Respondents
10,800 Responses
9,450 Hours (4,050 CM-911 and 5,400 CM-911a)

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 and 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.

Since the CM-911 and the CM-911a are generally completed and returned at the same time, a single mailing cost will be incurred for mailing both forms.  

Each respondent’s cost to mail both forms is estimated at 83¢ (78¢ stamp plus 05¢ for the envelope).  Thus, if every response were mailed, total respondent costs would be $4,482 (5,400 x 83¢ = $4,482.  This would be the total cost if we did not have any electronic submissions.

However, of the 5,400 responses, it is estimated that 30% will be submitted electronically through the COAL Mine Portal (5,400 x 30% = 1,620). The estimated savings of the forms submitted through the COAL mine portal is $1,344.60 (1,620 x 83¢=$1,344.60). The remaining 3,780 responses will be mailed to DCMWC with a respondent cost of $3,137.40 (3,780 x 83¢ = $3,137.40).

Therefore, the total respondent cost is $ 3,137 (rounded down) ($4,482-1,344.60=$ 3,137.40).

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), 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 total Federal Government cost is $264,627. (Processing costs + postage).  

  
An estimated 50% (2,700) of the CM-911 and CM-911a are sent together to the black lung applicants. 

    a. Estimated mailing cost: $2,133 (¢.74 metered postage plus ¢.05 per envelope = ¢0.79) 2,700 forms x ¢.79 = $2,133

    b. Estimated processing cost: $262,494. One claims examiner GS‑12/5 at a rate of $48.61 spends about 1 hour evaluating the two forms per respondent.
          $48.61 x 5,400= $262,494
          https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary- tables/pdf/2026/RUS_h.pdf   

$ 2,133 mailing costs + $262,494 processing costs = $264,627.

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

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:
Current: 10. Name of Most Recent Coal Mine Operator:______________
__________________________________________________

a. State of Most Recent Coal Mine Employment: ______

Proposed:
10. Name of Most Recent Coal Mine Operator:______________
__________________________________________________

    a. State of Most Recent Coal Mine Employment and Mine Site Name:







Question #16:
Current:


Proposed:

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.