OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Claim Adjudication Process for Alleged Presence of Pneumoconiosis

ICR 201311-1240-001 · OMB 1240-0023 · Historical Inactive

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 Unchanged Available
2013_1240-0023_CM-988,CM_933,_CM-933b,_CM-2907,_CM-1159(Final).docx Supporting Statement A Uploaded 2013-11-19 Repair queued
1240-0023 20CFR718.101 - 105.pdf Supplementary Document Uploaded 2011-05-27 Repair queued
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 Repair queued
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 Unchanged
ICR Details
1240-0023 201311-1240-001
Historical Inactive 201105-1240-001
DOL/OWCP
Claim Adjudication Process for Alleged Presence of Pneumoconiosis
Revision of a currently approved collection   No
Regular
Preapproved 12/27/2013
Retrieve Notice of Action (NOA) 11/19/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved 10/31/2014
24,000 0 24,000
5,840 0 5,840
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
1240-AA07 Proposed rulemaking 78 FR 35575 06/12/2013
78 FR 69449 11/19/2013
No
  Total Request 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 24,000 0 0 0 0
Annual Time Burden (Hours) 5,840 5,840 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$2,883,212
No
No
Yes
No
No
Uncollected
Debbie Thurston 202 693-0913 [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.
11/19/2013