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Federal forms, ICRs, and supporting documents

Information Collection Request

Claim Adjudication Process for Alleged Presence of Pneumoconiosis

ICR 201105-1240-001 · OMB 1240-0023 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-988 Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form Modified Repair queued
1240-0023_Supporting_Statement_A_08-25-2011.doc Supporting Statement A Uploaded 2011-08-25 Available
1240-0023 20CFR718.101 - 105.pdf Supplementary Document Uploaded 2011-05-27 Available
DOL Privacy Act systems ESA-30.pdf Supplementary Document Uploaded 2008-02-10 Repair queued
DOL Privacy Act systems ESA-6.pdf Supplementary Document Uploaded 2008-02-10 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13765 Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form Modified
ICR Details
1240-0023 201105-1240-001
Historical Active 201003-1240-023
DOL/OWCP
Claim Adjudication Process for Alleged Presence of Pneumoconiosis
Revision of a currently approved collection   No
Regular
Approved without change 10/31/2011
Retrieve Notice of Action (NOA) 08/31/2011
  Inventory as of this Action Requested Previously Approved
10/31/2014 36 Months From Approved 10/31/2011
24,000 0 17,500
5,840 0 4,259
0 0 0
20 CFR 718 specifies that certain information relative to the medical condition of a claimant who is alleging the presence of pneumoconiosis be obtained as a routine function of the claim adjudication process. The medical specifications in the regulations have been formatted in a variety of forms to promote efficiency and accuracy in gathering the required data. These forms were designed to meet the need to gather medical evidence.
US Code: 30 USC 901 Name of Law: Federal Coal Mine Health & Safety Act
  
None
Not associated with rulemaking
  76 FR 10070 02/23/2011
76 FR 54256 08/31/2011
No
  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 24,000 17,500 0 0 6,500 0
Annual Time Burden (Hours) 5,840 4,259 0 0 1,581 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The Patient Protection and Affordable Care Act of 2010 contained two provisions that affected the Black Lung Benefits Act. As a result, claim filings by coal miners have increased by over 50% since enactment. DCMWC expects that the rate of incoming claims will begin to decline in by FY 2012 and that the average annual intake of miners' claims will average 4,800. DOL has made some formatting changes to the forms associated with this information collection, technically making this submission a revision request; however, those cosmetic changes are not expected to change the burden.
$2,883,212
No
No
Yes
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.
08/31/2011