OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a

ICR 202311-1240-003 · OMB 1240-0038 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form Modified Repair queued
Miners Application CM-911 Non-material change request_MN (002) sc.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-11-07 Repair queued
1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx Supporting Statement A Uploaded 2023-09-13 Repair queued
725.404.docx Supplementary Document Uploaded 2018-04-10 Repair queued
System of Record Notice.pdf Supplementary Document Uploaded 2018-01-08 Repair queued
20CFR725.304 - Forms and initial processing.pdf Supplementary Document Uploaded 2014-08-08 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13681 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form Modified
ICR Details
1240-0038 202311-1240-003
Received in OIRA 202305-1240-002
DOL/OWCP
Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
No material or nonsubstantive change to a currently approved collection   No
Regular 11/16/2023
  Requested Previously Approved
10/31/2026 10/31/2026
10,020 10,020
8,768 8,768
2,420 2,420
CM-911 is the standard application form filed by the miner for benefits under the Black Lung Benefits Act. The applicant lists the coal miner's work history on the CM-911a, and this form is completed by all applicants, both miners and survivors.
US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  88 FR 38544 06/13/2023
88 FR 64929 09/20/2023
Yes
  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 10,020 10,020 0 0 0 0
Annual Time Burden (Hours) 8,768 8,768 0 0 0 0
Annual Cost Burden (Dollars) 2,420 2,420 0 0 0 0
No
No
$227,003
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.
11/16/2023