OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information for Black Lung Benefits

ICR 201505-1240-002 · OMB 1240-0034 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Available
2015 Supporting Statement 1240-0034 (CM-936).doc Supporting Statement A Uploaded 2015-08-12 Available
725.405.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
30 USC Sec. 902.pdf Supplementary Document Uploaded 2006-08-09 Available
30 USC Sec. 901.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
30 Chapter 22.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
DOL-ESA-30.pdf Supplementary Document Uploaded 2006-08-09 Available
DOL-ESA-6.pdf Supplementary Document Uploaded 2006-08-09 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13694 Authorization for Release of Medical Information Form Modified
ICR Details
1240-0034 201505-1240-002
Historical Active 201207-1240-001
DOL/OWCP
Authorization for Release of Medical Information for Black Lung Benefits
Revision of a currently approved collection   No
Regular
Approved without change 11/25/2015
Retrieve Notice of Action (NOA) 08/18/2015
  Inventory as of this Action Requested Previously Approved
11/30/2018 36 Months From Approved 11/30/2015
900 0 900
75 0 75
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
  80 FR 28302 05/18/2015
80 FR 50045 08/18/2015
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 900 900 0 0 0 0
Annual Time Burden (Hours) 75 75 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$3,835
No
No
No
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.
08/18/2015