OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

REPRESENTATIVES PAYEE REPORT, REPRESENTATIVES PAYEE REPORT (PART 2), PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT

ICR 199107-1215-006 · OMB 1215-0173 · Historical Active

Forms and Documents
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No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
122366 REPRESENTATIVES PAYEE REPORT, REPRESENTATIVES PAYEE REPORT (PART 2), PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT Form Migrated
ICR Details
1215-0173 199107-1215-006
Historical Active 199003-1215-003
DOL/ESA
REPRESENTATIVES PAYEE REPORT, REPRESENTATIVES PAYEE REPORT (PART 2), PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT
Revision of a currently approved collection   No
Regular
Approved without change 10/25/1991
Retrieve Notice of Action (NOA) 07/29/1991
We have approved these three information collection activities for two years for the following reason: DOL has not yet assessed the effectiveness of form CM-623 using concrete measures, as OMB directed in the previous terms of clearance. ESA explains that the form has no yet asked payees to complete and return the form, so the agency has no been able to make such measurements.
  Inventory as of this Action Requested Previously Approved
10/31/1993 10/31/1993 09/30/1991
2,750 0 2,750
2,250 0 3,813
0 0 0
REPRESENTATIVE PAYEE REPORT IS USED TO ENSURE BENEFITS CERTIFIED AND PAID TO A REPRESENTATIVE ARE BEING USED FOR THE BENEFICIARY'S WELL BEING. PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT IS USED TO DETERMINE THE BENEFICIARY'S CAPABILITY TO MANAGE MONTHLY BLACK LUNG BENEFITS.
None
None
No
1
IC Title Form No. Form Name
REPRESENTATIVES PAYEE REPORT, REPRESENTATIVES PAYEE REPORT (PART 2), PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT CM-623, CM-623S, CM-787
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,750 2,750 0 0 0 0
Annual Time Burden (Hours) 2,250 3,813 0 -1,563 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/29/1991