OMB control number

Claim Adjudication Process for the Alleged Presence of Pneumoconiosis

OMB 1240-0023 · DOL/OWCP.

OMB 1240-0023

As part of the claim adjudication process, 20 CFR 718 requires certain medical information be obtained regarding the medical condition of a claimant alleging the presence of pneumoconiosis. The medical specifications in the regulations have been formatted in a variety of forms to promote efficiency and accuracy in gathering the required data. These forms were designed to meet the need to gather medical evidence.

The latest form for Claim Adjudication Process for the Alleged Presence of Pneumoconiosis expires 2026-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
SS 1240-0023 2023_MN-MM.docx Supporting Statement A
SS 1240-0023 2023_MN-MM.docx Supporting Statement A
Justification 1240-0023.docx Justification for No Material/Nonsubstantive Change
Justification 1240-0023.docx Justification for No Material/Nonsubstantive Change
725.406.pdf Supplementary Document
725.406.pdf Supplementary Document
718.204.pdf Supplementary Document
718.204.pdf Supplementary Document
718.202.pdf Supplementary Document
718.202.pdf Supplementary Document
DOL-OWCP-9.pdf Supplementary Document
DOL-OWCP-9.pdf Supplementary Document
CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis.pdf Supplementary Document
DOL-OWCP-2.pdf Supplementary Document
1240-0023 20CFR718.101 - 105.pdf Supplementary Document
1240-0023 20CFR718.101 - 105.pdf Supplementary Document
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form

All Historical Document Collections

202401-1240-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-01-31
202306-1240-001 Approved without change	Revision of a currently approved collection	2023-10-04
202005-1240-001 Approved without change	Revision of a currently approved collection	2020-08-19
202002-1240-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-02-21
201703-1240-004 Approved without change	Revision of a currently approved collection	2017-05-31
201412-1240-015 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-05-14
201405-1240-003 Approved without change	Revision of a currently approved collection	2014-05-20
201311-1240-001 Preapproved	Revision of a currently approved collection	2013-11-19
201105-1240-001 Approved without change	Revision of a currently approved collection	2011-08-31
201003-1240-023 Approved with change	Extension without change of a currently approved collection	2010-03-12