Information Collection

1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History

IC 13681 under ICR 202603-1240-005 · OMB 1240-0038.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-911 Miner’s Claim for Benefits Under the Black Lung Benefits Act CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form
Form CM-911a Employment History 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History	Form
CM-911 Miner’s Claim for Benefits Under the Black Lung Benefits CM-911 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-911a Employment History CM-911a Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.304(a)

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
Form	CM-911			https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Fileable Signable
Form	CM-911a			https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-2

FR Citation: 67 FR 16869

Number of Respondents: 5,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,800	780	10,020
Annual IC Time Burden (Hours)	9,450	682	8,768
Annual IC Cost Burden (Dollars)	3,137	717	2,420

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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