OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information (Black Lung Benefits)

ICR 200903-1215-002 · OMB 1215-0057 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Available
ss 1215-0057 (CM-936) 7-07-09.doc Supporting Statement A Uploaded 2009-07-13 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 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13694 Authorization for Release of Medical Information Form Modified
ICR Details
1215-0057 200903-1215-002
Historical Active 200608-1215-004
DOL/ESA
Authorization for Release of Medical Information (Black Lung Benefits)
Extension without change of a currently approved collection   No
Regular
Approved without change 11/03/2009
Retrieve Notice of Action (NOA) 08/24/2009
  Inventory as of this Action Requested Previously Approved
11/30/2012 36 Months From Approved 11/30/2009
900 0 1,200
75 0 100
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
  74 FR 15005 04/02/2009
74 FR 42693 08/24/2009
No
1
IC Title Form No. Form Name
Authorization for Release of Medical Information CM-936 Authorization for Release of Medical Information (Black Lung)
  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 900 1,200 0 0 -300 0
Annual Time Burden (Hours) 75 100 0 0 -25 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The reduction of 100 hours to 75 hours is due to a decline 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 The Division of Coal Mine Workers' Compensation (DCMWC) is required to request medical records.
$3,269
No
No
Uncollected
Uncollected
No
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.
08/24/2009