OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for State or Federal Workers' Compensation Information

ICR 201008-1240-001 · OMB 1240-0032 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-905 Request for State or Federal Workers' Compensation Information Form Modified Repair queued
CM-905.doc Supplementary Document Uploaded 2007-07-11 Available
725 535.pdf Supplementary Document Uploaded 2007-06-11 Repair queued
30 USC 924.pdf Supplementary Document Uploaded 2007-06-11 Repair queued
DOL Privacy Act systems ESA-30.pdf Supplementary Document Uploaded 2007-06-11 Available
Supporting Statement for 1240-0032 (CM-905) April 2010.doc Supporting Statement A Uploaded 2010-08-03 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13703 Request for State or Federal Workers' Compensation Information Form Modified
ICR Details
1240-0032 201008-1240-001
Historical Active 201003-1240-032
DOL/OWCP
Request for State or Federal Workers' Compensation Information
Revision of a currently approved collection   No
Regular
Approved without change 10/18/2010
Retrieve Notice of Action (NOA) 08/18/2010
  Inventory as of this Action Requested Previously Approved
10/31/2013 36 Months From Approved 10/31/2010
1,400 0 1,400
350 0 350
658 0 616
DCMWC beneficiaries have their monthly benefits reduced dollar for dollar for other benefits that they receive attributable to their black lung disability from State or Federal workers' benefits. The CM-905 request the amount of those workers' compensation benefits.
US Code: 30 USC 901 Name of Law: The Federal Mine Safety and Health Act of 1977, as amended
  
None
Not associated with rulemaking
  75 FR 21351 04/23/2010
75 FR 50782 08/17/2010
No
1
IC Title Form No. Form Name
Request for State or Federal Workers' Compensation Information CM-905 Request for State or Federal Workers' Compensation Information
  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 1,400 1,400 0 0 0 0
Annual Time Burden (Hours) 350 350 0 0 0 0
Annual Cost Burden (Dollars) 658 616 0 42 0 0
No
No
$12,599
No
No
No
No
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.
08/18/2010