OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information for Black Lung Benefits

ICR 202010-1240-004 · OMB 1240-0034 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Available
Justification - Authorization for Release of Medical Information (Black Lung Benefits) (CM-936).docx Justification for No Material/Nonsubstantive Change Uploaded 2020-10-22 Available
System of Record Notice-DOL OWCP-2.pdf Supplementary Document Uploaded 2018-09-27 Available
Supporting Statement 1240-0034 (CM-936) 2018.doc Supporting Statement A Uploaded 2018-11-02 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 Available
30 Chapter 22.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
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 202010-1240-004
Active 202003-1240-004
DOL/OWCP
Authorization for Release of Medical Information for Black Lung Benefits
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/03/2020
Retrieve Notice of Action (NOA) 10/23/2020
  Inventory as of this Action Requested Previously Approved
02/28/2022 02/28/2022 02/28/2022
7,000 0 7,000
583 0 583
0 0 0
Address change for CM-936 form. 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 7,000 0 0 0 0
Annual Time Burden (Hours) 583 583 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$30,653
No
    Yes
    Yes
No
No
No
No
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.
10/23/2020