Certification by School Official

Forms and Documents

Document Name	Status
Form CM-981 Certification By School Official Form	Modified
CM-981 Certification by School Official.pdf Supplementary Document	2020-02-28
Justification - Certification by School Official - CM-981.docx Justification for No Material/Nonsubstantive Change	2020-02-28
20191202 Supporting Statement CM-981 (7-14-2020).docx Supporting Statement A	2020-07-14
30 USC 901-945.pdf Supplementary Document	2019-10-09
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2019-10-09
725.209 to 725.218.pdf Supplementary Document	2019-10-09

IC Document Collections

IC ID	Document Title	Status
13706	Certification By School Official Form	Modified

ICR Details

OMB Control No: 1240-0031	ICR Reference No: 201909-1240-001
Status: Historical Active	Previous ICR Reference No: 201601-1240-012
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Certification by School Official
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/15/2020
	Date Received in OIRA: 02/04/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved
Responses	100	0	0
Time Burden (Hours)	17	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: CM-981 is completed by a school official to verify whether a Black Lung beneficiary's dependent, aged 18 to 23, qualifies as a full-time student.

---

Authorizing Statute(s): US Code: 30 USC 901-944 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 64567	11/22/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 5995	02/03/2020
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Certification By School Official	CM-981	Certification by School Official

---

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	100	0	0	0	-393	493
Annual Time Burden (Hours)	17	0	0	0	-65	82
Annual Cost Burden (Dollars)	0	0	0	0	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: The estimated number of completed collections of information is reduced to 100, from 493. Likewise the respondent burden hours are reduced to 17 from 82. There are fewer eligible dependents attending school full-time.

---

Annual Cost to Federal Government: $825

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

Common Form ICR:  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:

(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: 02/04/2020

---