Information Collection Request
Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
ICR 202402-1240-002 · OMB 1240-0038 · Active
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History |
Form | Modified | Available |
| Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History |
Form | Modified | Repair queued |
 Justification CM-911 & CM-911a Translated in Spanish.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-02-21 | Available |
| Justification CM-911 & CM-911a Translated in Spanish.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-02-21 | Repair queued |
| 1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx |
Supporting Statement A | Uploaded 2024-01-30 | Available |
| 1240-0038_Supporting Statement_DEIA 9.12.23_MN.docx |
Supporting Statement A | Uploaded 2024-01-30 | Missing upstream |
| Justification CM-911 & CM-911a.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-01-30 | Available |
| Justification CM-911 & CM-911a.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-01-30 | Repair queued |
| 725.404.docx |
Supplementary Document | Uploaded 2018-04-10 | Available |
| 725.404.docx |
Supplementary Document | Uploaded 2018-04-10 | Missing upstream |
 System of Record Notice.pdf |
Supplementary Document | Uploaded 2018-01-08 | Available |
| System of Record Notice.pdf |
Supplementary Document | Uploaded 2018-01-08 | Missing upstream |
| 20CFR725.304 - Forms and initial processing.pdf |
Supplementary Document | Uploaded 2014-08-08 | Available |
| 20CFR725.304 - Forms and initial processing.pdf |
Supplementary Document | Uploaded 2014-08-08 | Missing upstream |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 13681 |  1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History |
Form | Modified | |
| 13681 | 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History |
Form | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0038 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202401-1240-012 |
| Date Submitted to OIRA | 2024-03-13 |
| Requested Expiration Date | 1969-12-31 |