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Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information (Black Lung Benefits)

ICR 200608-1215-004 · OMB 1215-0057 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Available
725.408.pdf Supplementary Document Uploaded 2006-08-09 Available
725.407.pdf Supplementary Document Uploaded 2006-08-09 Available
725.406.pdf Supplementary Document Uploaded 2006-08-09 Available
725.405.pdf Supplementary Document Uploaded 2006-08-09 Available
30 USC Sec. 902.pdf Supplementary Document Uploaded 2006-08-09 Available
30 USC Sec. 901.pdf Supplementary Document Uploaded 2006-08-09 Available
30 Chapter 22.pdf Supplementary Document Uploaded 2006-08-09 Available
DOL-ESA-30.pdf Supplementary Document Uploaded 2006-08-09 Available
DOL-ESA-6.pdf Supplementary Document Uploaded 2006-08-09 Available
ss 1215-0057 (CM-936) May 4, 2006.doc Supporting Statement A Uploaded 2006-08-09 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13694 Authorization for Release of Medical Information Form Modified
ICR Details
1215-0057 200608-1215-004
Historical Active 200309-1215-003
DOL/ESA
Authorization for Release of Medical Information (Black Lung Benefits)
Extension without change of a currently approved collection   No
Regular
Approved with change 10/17/2006
Retrieve Notice of Action (NOA) 08/18/2006
Approved consistent with memo 10/16.
  Inventory as of this Action Requested Previously Approved
10/31/2009 36 Months From Approved 11/30/2006
1,200 0 1,500
100 0 125
0 0 0
The CM-936 is used to obtain the black lung claimant's authorization for the Division of Coal Mine Workers' Compensation to request medical evidence in support of the black lung claim.
US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  71 FR 105 06/01/2006
71 FR 158 08/16/2006
No
1
IC Title Form No. Form Name
Authorization for Release of Medical Information CM-936 Authorization for Release of Medical Information (Black Lung Benefits)
  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 1,200 1,500 0 0 -300 0
Annual Time Burden (Hours) 100 125 0 0 -25 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The estimated burden hour is an adjustment downward from 125 burden hours to 100 hours which is a decrease of -25 hours. The reduction is due to a decrease in the number of persons applying for black lung benefits, and because a change in program regulations in 2001 has reduced the number of claimants for which DCMWC is required to request medical records.
$7,196
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Michael McClaran 202-693-0978 [email protected]
  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.
08/18/2006