Approved as amended by DOL memorandum of 4/23/96, 4/24/96 and 4/25/96. It is noted however that ESA shall recognize in future PRA submissions that there is a burden cost placed on the beneficiaries when filling out these forms despite the respondents current employment status.
Inventory as of this Action
Requested
Previously Approved
05/31/1999
05/31/1999
04/30/1996
20,200
0
52,700
9,116
0
14,533
3,000
0
0
CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. CM-911a lists the coal miner's work history and is completed by all applicants, miners, and survivors. CM-915 is used by the miner or survivor for requesting reimbursement of medical expenses incurred and paid by a miner beneficiary.
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.
Miner's Claim for Benefits under the Black Lung Benefits Act, Employment History, Miner Reimbursement Form