OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization for Release of Medical Information for Black Lung Benefits

ICR 202409-1240-002 · OMB 1240-0034 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CM-936 Authorization for Release of Medical Information Form Modified Available
Supporting Statement 1240-0034-12-11.24.docx Supporting Statement A Uploaded 2024-12-11 Available
System of Record Notice-DOL OWCP-2.pdf Supplementary Document Uploaded 2018-09-27 Missing upstream
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 Repair queued
30 Chapter 22.pdf Supplementary Document Uploaded 2006-08-09 Repair queued
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 202409-1240-002
Received in OIRA 202401-1240-009
DOL/OWCP
Authorization for Release of Medical Information for Black Lung Benefits
Revision of a currently approved collection   No
Regular 12/12/2024
  Requested Previously Approved
36 Months From Approved 03/31/2025
5,990 5,000
1,995 417
0 0
OWCP Form 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
  89 FR 72900 11/05/2024
89 FR 10053 12/12/2024
No
1
IC Title Form No. Form Name
Authorization for Release of Medical Information CM-936 Authorization For Release Of Medical Information (Black Lung Benefits)
  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 5,990 5,000 0 990 0 0
Annual Time Burden (Hours) 1,995 417 0 1,578 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Respondents: The number of respondents increased from 5,000 to 5,990. The following also increased due to an increased in number of respondents. Responses: Responses have increased from 5,000 to 5,990. Burden Hours: Burden hours have increased from 417 to 1,995. The current version of the CM-936 requested information from a single medical provider. The revised form, however, accommodates information from up to four providers. As a result, DCMWC anticipates that completing the form may take up to four times longer than before. Consequently, the Public Burden Statement has been adjusted to reflect this increase, with the estimated completion time now averaging 20 minutes, up from the previous average of 5 minutes. Costs: No other cost reported for this collection.
$8,865
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.
12/12/2024