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
SS 1240-0032 2016.doc Supporting Statement A	2016-10-19
DOL Privacy Act Systems ESA-6.pdf Supplementary Document	2013-09-23
20 CFR 725 535.pdf Supplementary Document	2013-06-25
30 USC 924.pdf Supplementary Document	2013-06-25
DOL Privacy Act Systems ESA-30.pdf Supplementary Document	2013-06-25

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: 201607-1240-002
Status: Historical Active	Previous ICR Reference No: 201306-1240-005
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: 02/06/2017
	Date Received in OIRA: 12/28/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/28/2017
Responses	2,000	0	2,000
Time Burden (Hours)	500	0	500
Cost Burden (Dollars)	1,000	0	980

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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:
	81 FR 49270	07/27/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 95648	12/28/2016
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	2,000	2,000	0	0	0	0
Annual Time Burden (Hours)	500	500	0	0	0	0
Annual Cost Burden (Dollars)	1,000	980	0	0	20	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: $18,360

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: 12/28/2016

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