Request for State or Federal Workers' Compensation Information

Forms and Documents

Document Name	Status
Form CM-905 Request for State or Federal Workers' Compensation Information Form	Modified
CM-905.doc Supplementary Document	2007-07-11
725 535.pdf Supplementary Document	2007-06-11
30 USC 924.pdf Supplementary Document	2007-06-11
DOL Privacy Act systems ESA-30.pdf Supplementary Document	2007-06-11
Supporting Statement for 1240-0032 (CM-905) April 2010.doc Supporting Statement A	2010-08-03

IC Document Collections

IC ID	Document Title	Status
13703	Request for State or Federal Workers' Compensation Information Form	Modified

ICR Details

OMB Control No: 1240-0032	ICR Reference No: 201008-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-032
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for State or Federal Workers' Compensation Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/18/2010
	Date Received in OIRA: 08/18/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	10/31/2010
Responses	1,400	0	1,400
Time Burden (Hours)	350	0	350
Cost Burden (Dollars)	658	0	616

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Abstract: DCMWC beneficiaries have their monthly benefits reduced dollar for dollar for other benefits that they receive attributable to their black lung disability from State or Federal workers' benefits. The CM-905 request the amount of those workers' compensation benefits.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: The Federal Mine Safety and Health Act of 1977, as amended
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 21351	04/23/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 50782	08/17/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for State or Federal Workers' Compensation Information	CM-905	Request for State or Federal Workers' Compensation Information

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ICR Summary of Burden

	Total Approved	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	1,400	1,400	0	0	0	0
Annual Time Burden (Hours)	350	350	0	0	0	0
Annual Cost Burden (Dollars)	658	616	0	42	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $12,599

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/18/2010

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