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Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 1240-0038 · DOL/OWCP.

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 2026-10-31 and is listed under ICR 202402-1240-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment HistoryForm
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment HistoryForm
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.docxSupporting Statement A
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docxSupporting 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All Historical Document Collections

Historical document collections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