OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information for Black Lung Benefits

ICR 201809-1240-001 · OMB 1240-0034 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Repair queued
System of Record Notice-DOL OWCP-2.pdf Supplementary Document Uploaded 2018-09-27 Available
NOTE TO REVIEWER_20160314.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-03-14 Repair queued
Supporting Statement 1240-0034 (CM-936) 2018.doc Supporting Statement A Uploaded 2018-11-02 Repair queued
725.405.pdf Supplementary Document Uploaded 2006-08-09 Available
30 USC Sec. 902.pdf Supplementary Document Uploaded 2006-08-09 Available
30 USC Sec. 901.pdf Supplementary Document Uploaded 2006-08-09 Available
30 Chapter 22.pdf Supplementary Document Uploaded 2006-08-09 Available
DOL-ESA-30.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 201809-1240-001
Historical Active 201602-1240-006
DOL/OWCP
Authorization for Release of Medical Information for Black Lung Benefits
Revision of a currently approved collection   No
Regular
Approved without change 02/14/2019
Retrieve Notice of Action (NOA) 11/30/2018
  Inventory as of this Action Requested Previously Approved
02/28/2022 36 Months From Approved 02/28/2019
7,000 0 900
583 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
  83 FR 45142 09/05/2018
83 FR 61682 11/30/2018
No
1
IC Title Form No. Form Name
Authorization for Release of Medical Information CM-936 Authorization For Release of Medical 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 7,000 900 0 0 6,100 0
Annual Time Burden (Hours) 583 75 0 0 508 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There has been a significant increase in the number of respondents, as well as their burden hours. This is due to current instructions to use this form in all claims filed rather than on an as needed basis.
$30,653
No
    Yes
    Yes
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.
11/30/2018