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

OMB 1240-0038

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 this form is completed by all applicants, both miners and survivors.

The latest form for Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a expires 2022-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
Justification CM-911 & CM-911a Translated in Spanish.docx Justification for No Material/Nonsubstantive Change
Justification CM-911 & CM-911a Translated in Spanish.docx Justification for No Material/Nonsubstantive Change
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx Supporting Statement A
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx Supporting Statement A
Justification CM-911 & CM-911a.docx Justification for No Material/Nonsubstantive Change
Justification CM-911 & CM-911a.docx Justification for No Material/Nonsubstantive Change
725.404.docx Supplementary Document
725.404.docx Supplementary Document
System of Record Notice.pdf Supplementary Document
System of Record Notice.pdf Supplementary Document
20CFR725.304 - Forms and initial processing.pdf Supplementary Document
20CFR725.304 - Forms and initial processing.pdf Supplementary Document
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form

All Historical Document Collections

202402-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-03-13
202401-1240-012 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-01-31
202311-1240-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-11-16
202305-1240-002 Approved without change	Revision of a currently approved collection	2023-09-20
202109-1240-003 Approved without change	Revision of a currently approved collection	2022-02-25
201712-1240-003 Approved without change	Reinstatement with change of a previously approved collection	2019-02-15
201602-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-03-02
201405-1240-005 Approved with change	Revision of a currently approved collection	2014-10-22
201107-1240-002 Approved without change	Extension without change of a currently approved collection	2011-09-29
201003-1240-038 Approved without change	Extension without change of a currently approved collection	2010-03-12