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Federal forms, ICRs, and supporting documents

OMB control number

Claim Adjudication Process for the Alleged Presence of Pneumoconiosis

OMB 1240-0023 · DOL/OWCP.

OMB 1240-0023

As part of the claim adjudication process, 20 CFR 718 requires certain medical information be obtained regarding the medical condition of a claimant alleging the presence of pneumoconiosis. The medical specifications in the regulations have been formatted in a variety of forms to promote efficiency and accuracy in gathering the required data. These forms were designed to meet the need to gather medical evidence.

The latest form for Claim Adjudication Process for the Alleged Presence of Pneumoconiosis expires 2026-11-30 and is listed under ICR 202401-1240-006.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....Form
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....Form
SS 1240-0023 2023_MN-MM.docxSupporting Statement A
SS 1240-0023 2023_MN-MM.docxSupporting Statement A
Justification 1240-0023.docx Justification for No Material/Nonsubstantive Change
Justification 1240-0023.docx Justification for No Material/Nonsubstantive Change
725.406.pdf Supplementary Document
725.406.pdf Supplementary Document
718.204.pdf Supplementary Document
718.204.pdf Supplementary Document
718.202.pdf Supplementary Document
718.202.pdf Supplementary Document
DOL-OWCP-9.pdf Supplementary Document
DOL-OWCP-9.pdf Supplementary Document
CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis.pdf Supplementary Document
CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis.pdf Supplementary Document
DOL-OWCP-2.pdf Supplementary Document
DOL-OWCP-2.pdf Supplementary Document
1240-0023 20CFR718.101 - 105.pdf Supplementary Document
1240-0023 20CFR718.101 - 105.pdf Supplementary Document
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202401-1240-006 No material or nonsubstantive change to a currently approved collection 2024-01-31 Approved without change
202306-1240-001 Revision of a currently approved collection 2023-10-04 Approved without change
202005-1240-001 Revision of a currently approved collection 2020-08-19 Approved without change
202002-1240-006 No material or nonsubstantive change to a currently approved collection 2020-02-21 Approved without change
201703-1240-004 Revision of a currently approved collection 2017-05-31 Approved without change
201412-1240-015 No material or nonsubstantive change to a currently approved collection 2015-05-14 Approved without change
201405-1240-003 Revision of a currently approved collection 2014-05-20 Approved without change
201311-1240-001 Revision of a currently approved collection 2013-11-19 Preapproved
201105-1240-001 Revision of a currently approved collection 2011-08-31 Approved without change
201003-1240-023 Extension without change of a currently approved collection 2010-03-12 Approved with change