OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History

ICR 201602-1240-004 · OMB 1240-0038 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-911A 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form Modified Repair queued
NOTICE TO REVIEWER.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-02-11 Repair queued
2014 Supporting Statement Revised 1240-0038 CM-911 and CM-911a (20150115).doc Supporting Statement A Uploaded 2015-01-20 Repair queued
20CFR725.304 - Forms and initial processing.pdf Supplementary Document Uploaded 2014-08-08 Available
DOL Privacy Act systems ESA-30.pdf Supplementary Document Uploaded 2014-08-08 Available
DOL Privacy Act systems ESA-6.pdf Supplementary Document Uploaded 2014-08-08 Available
20CFR725.404 - Development of evidence--general.docx Supplementary Document Uploaded 2014-08-08 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13681 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form Modified
ICR Details
1240-0038 201602-1240-004
Historical Active 201405-1240-005
DOL/OWCP
Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/04/2016
Retrieve Notice of Action (NOA) 03/02/2016
  Inventory as of this Action Requested Previously Approved
01/31/2018 01/31/2018 01/31/2018
11,000 0 11,000
7,750 0 7,750
2,058 0 2,058
CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and this form is completed by all applicants, both miners and survivors.
US Code: 30 USC 901 Name of Law: null
  
None
Not associated with rulemaking
  79 FR 29218 05/21/2014
79 FR 63169 10/22/2014
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 11,000 11,000 0 0 0 0
Annual Time Burden (Hours) 7,750 7,750 0 0 0 0
Annual Cost Burden (Dollars) 2,058 2,058 0 0 0 0
No
No
$210,130
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.
03/02/2016