OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Claim Adjudication Process for Alleged Presence of Pneumoconiosis

ICR 202002-1240-006 · OMB 1240-0023 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-933b Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form Unchanged Available
Justifiction - CM-988.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-02-19 Available
CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis.pdf Supplementary Document Uploaded 2020-02-19 Available
System of Record Notice.pdf Supplementary Document Uploaded 2017-05-22 Repair queued
1240-0023 Supporting Statement 2017.doc Supporting Statement A Uploaded 2017-05-24 Available
Notice To Reviewer.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-05-14 Repair queued
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 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13765 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form Unchanged
ICR Details
1240-0023 202002-1240-006
Historical Active 201703-1240-004
DOL/OWCP
Claim Adjudication Process for Alleged Presence of Pneumoconiosis
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 02/27/2020
Retrieve Notice of Action (NOA) 02/21/2020
  Inventory as of this Action Requested Previously Approved
08/31/2020 08/31/2020 08/31/2020
27,500 0 27,500
6,693 0 6,693
0 0 0
Request for address change; Request for 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 957 Name of Law: Black Lung Benefits Act of 1977, as amended
  
None
Not associated with rulemaking
  82 FR 10411 02/10/2017
82 FR 24992 05/31/2017
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 27,500 27,500 0 0 0 0
Annual Time Burden (Hours) 6,693 6,693 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The annual number of responses changed to 27,500 from 24,000, estimated total burden hours changed to 6,693 hours from 5,840 hours due to the increase of completing and mailing each form. Numerous minor changes were made to each information collection instrument, but these are not expected to change burden..
$5,569,503
No
    Yes
    Yes
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.
02/21/2020