Miner's Claim For Benefits Under The Black Lung Benefits Act, History Of Coal Mine Employment, And Drug, Respiratory Therapy, Oxygen And Medical Equipment Reimbursement Form

MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT, HISTORY OF COAL MINE EMPLOYMENT, AND DRUG, RESPIRATORY THERAPY, OXYGEN AND MEDICAL EQUIPMENT REIMBURSEMENT FORM

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Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	MINER'S CLAIM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT, HISTORY OF COAL MINE EMPLOYMENT, AND DRUG, RESPIRATORY THERAPY, OXYGEN AND MEDICAL EQUIPMENT REIMBURSEMENT FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CM-911,	No	No
Form	CM-911A,	No	No
Form	& CM-915	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 97,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	172,000	-338,000	510,000
Annual IC Time Burden (Hours)	28,083	-111,917	140,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.