OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information for Black Lung Benefits

ICR 202111-1240-003 · OMB 1240-0034 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Repair queued
Supporting Statement - 1240-0034 Final.docx Supporting Statement A Uploaded 2022-01-19 Available
System of Record Notice-DOL OWCP-2.pdf Supplementary Document Uploaded 2018-09-27 Repair queued
725.405.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
30 USC Sec. 902.pdf Supplementary Document Uploaded 2006-08-09 Missing upstream
30 USC Sec. 901.pdf Supplementary Document Uploaded 2006-08-09 Missing upstream
30 Chapter 22.pdf Supplementary Document Uploaded 2006-08-09 Missing upstream
DOL-ESA-30.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13694 Authorization for Release of Medical Information Form Modified
ICR Details
1240-0034 202111-1240-003
Received in OIRA 202010-1240-004
DOL/OWCP
Authorization for Release of Medical Information for Black Lung Benefits
Extension without change of a currently approved collection   No
Regular 01/20/2022
  Requested Previously Approved
36 Months From Approved 02/28/2022
5,000 7,000
417 583
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
  86 FR 50909 09/13/2021
87 FR 3127 01/20/2022
No
1
IC Title Form No. Form Name
Authorization for Release of Medical Information CM-936 Authorization For Release of Medical Information
  Total Request 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 5,000 7,000 0 0 -2,000 0
Annual Time Burden (Hours) 417 583 0 0 -166 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There has been a decreased in the number of respondents, as well as the burden hours. This is due to the decrease in the number of claims filed during the pandemic.
$5,300
No
    Yes
    Yes
No
No
No
No
Marcela Meneses 304 420-1232 [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.
01/20/2022