OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Survivor's Form for Benefits Under the Black Lung Benefits Act

ICR 202304-1240-004 · OMB 1240-0027 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form Modified Missing upstream
SS 1240-0027 CM-912 2023_OCIO-Final.docx Supporting Statement A Uploaded 2023-08-31 Repair queued
DOL-OWCP-9.pdf Supplementary Document Uploaded 2020-03-03 Repair queued
725.212 to 725.225.docx Supplementary Document Uploaded 2020-03-03 Repair queued
CFR 725.304.pdf Supplementary Document Uploaded 2019-11-26 Missing upstream
System of Record Notice-DOL OWCP-2.pdf Supplementary Document Uploaded 2019-11-26 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
13721 Survivor's Form for Benefits Under the Black Lung Benefits Act Form Modified
ICR Details
1240-0027 202304-1240-004
Received in OIRA 201911-1240-004
DOL/OWCP
Survivor's Form for Benefits Under the Black Lung Benefits Act
Revision of a currently approved collection   No
Regular 09/07/2023
  Requested Previously Approved
36 Months From Approved 10/31/2023
1,067 850
142 113
707 377
The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.
US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  88 FR 29698 05/08/2023
88 FR 61617 09/07/2023
No
1
IC Title Form No. Form Name
Survivor's Form for Benefits Under the Black Lung Benefits Act CM-912 Survivor's For for Benefits Under the Black Lung Benefits Act
  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 1,067 850 0 217 0 0
Annual Time Burden (Hours) 142 113 0 29 0 0
Annual Cost Burden (Dollars) 707 377 0 330 0 0
Yes
Miscellaneous Actions
No
The number of respondents increased from 850 to 1,067. The number of respondents increased due to an increase of claims field.
$12,690
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.
09/07/2023