Supporting Statement 1240-0028 (CM-929 and 929P)

SUPPORTING STATEMENT

Report of Changes That May Affect Your Black Lung Benefits

CM-929 and CM-929P

OMB No. 1240-0028 (Formerly 1215-0084)

A. Justification.

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

The Federal Mine Safety and Health Act of 1977, as amended, 30 USC 936, 30 USC 941 and 20 CFR 725.533(e) authorizes the Division of Coal Mine Workers’ Compensation (DCMWC) to pay compensation to coal miner beneficiaries. Once a miner or survivor is found eligible for benefits, the primary beneficiary is requested to report certain changes that may affect benefits. To ensure that there is a review and update of all claims paid from the Black Lung Disability Trust Fund, and from Social Security cases transferred to the Department of Labor under the Black Lung Consolidation of Administrative Responsibility Act of 2002, and to help the beneficiary comply with the need to report certain changes, the CM‑929 is sent to all appropriate primary beneficiaries. The CM‑929 is printed by the Division of Coal Mine Workers' Compensation (DCMWC) computer system with information specific to each beneficiary, such as name, address, number of dependents on record, state workers’ compensation information, and amount of current benefits. The beneficiary reviews the information and certifies that the information is current, or provides updated information. The form includes a warning about potential consequences of failure to report changes.

DCMWC uses Information Collection OMB 1240-0020, Forms CM-623 and CM-623S, to monitor a representative payee’s use of funds paid on a beneficiary’s behalf. This is an annual reporting requirement and, while the information collected on OMB 1240-0028 and 1240-0020 is different, the same payees complete both forms and the same DCMWC claims examiner reviews them. Therefore, DCMWC incorporated the CM-929 into the CM-623 and CM-623S in those cases that appropriately had been sent both forms. This composite form is entitled CM-929P, and allows respondents to verify information to DCMWC once annually instead of twice.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The CM-929 is used to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Black Lung Disability Trust Fund. The CM-929 is completed by the beneficiary to report factors that may affect his or her benefits, including income, marital status, receipt of state workers' compensation, and dependents’ status. Primary beneficiaries are requested to complete the form upon receipt. The claims examiner carefully reviews the response, verifies information in the claim file, and identifies changes, such as income, marital and dependent status, that may need verification. This information reduces the potential for overpayments and for underpayments. The claims examiner insures that the computer system is updated to reflect appropriate changes.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act (GPEA), the forms in this information collection were considered but found to be not practicable for electronic submission. The respondents are retired, disabled coal mine workers and elderly widows. Given the demographics of the customer base, it is unlikely that any significant proportion would have access to the electronic option. It would not be cost effective to make the form electronically interactive for a population that would be unlikely to benefit from such an option. The claim of likely low electronic filing by respondents is based on agency knowledge of its customers; however, no empirical data is available other than the certain fact that the Division of Coal Mine Workers’ Compensation has never received an electronic submission of any information collection that has been available for electronic submission, including those forms that a claimant would provide.  During the current authorization, headquarters staff knowledgeable about this program is unaware of DCMWC having received any Forms CM-929 or CM-929p downloaded from the Internet.  No downloaded forms are understandable, because—as indicated in Supporting Statement item 1—DCMWC pre-populates data about the beneficiary on Forms CM-929 and CM-929p.  The agency has no mechanism to provide an electronic filing option to an individual with the relevant data pre-populated,  Among the difficulties would be developing a reliable method for ensuring respondents receive notice of the need to update information along with the individualized data, and would ensure that highly-sensitive financial information and Personally Identifiable Information would be protected. However, even though each form issued by DCMWC is payee-specific and computer‑generated, the forms are available for downloading and mailing on the DCMWC home page at http://www.dol.gov/owcp/regs/compliance/cm-929.pdf and http://www.dol.gov/owcp/regs/compliance/cm-929p.pdf in case claimants misplace the partially completed one that is sent to them. The CM-929 and CM-929p will also be accessible through DOL's on-line forms library at http://webapps.dol.gov/libraryforms/FormsByNum.asp.

4. Describe efforts to identify duplication. show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

Other Federal agencies have similar reporting requirements, one of which is the Division of Federal Employees' Compensation's Periodic Roll Review. The similar information requested by other agencies cannot be used or modified for the Black Lung Program because our form, CM-929 and CM-929p, are beneficiary and Program-specific. Even though the application for benefits requests that specific changes be reported, the CM‑929 and CM-929p are the only existing methods to systematically update the information listed on the application which may affect the amount of benefits and to insure that the beneficiary knows to report those changes.

5. If the collection information impacts small businesses or other small entities (Item 5 of 014B Form 83-1), describe any methods used to minimize burden.

This information collection does not have a significant economic impact on a substantial number of small entities.

6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

DCMWC recognizes that an increasing percentage of its beneficiaries require assistance and more careful monitoring because the average age of beneficiaries has grown, and has changed its scheduled mailings of the questionnaires accordingly. The information is requested annually. If the information update were done less frequently, there would be a higher risk of overpayments, underpayments, and erroneous payments to payees due to unreported changes in status.

7. Explain any special circumstance that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentially that is not supported by authority established in statue or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can prove that it has instituted procedures to protect the information's confidentially to the extent permitted by law.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.

During the development of the form, DCMWC utilized the comments of district office and national office staff and the outside consultation of its computer contractor. DCMWC staff has been in contact with form users on an ongoing basis to lend assistance when needed and to monitor the form's usefulness and efficiency. The beneficiaries have found the form easy to understand and complete.

A notice inviting public comment on this information collection was published in the Federal Register on March 14, 2011 in Vol. 76, No. 49 Page 13669. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

Respondents do not receive gifts or payments to furnish the requested information. However, the respondents are entitled to and do receive monthly benefits.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

The Privacy Act System (ESA‑6 and ESA-30) provides confidentially of information collection involving a claimant's records. Additionally, the Form CM-929 displays a Privacy Act disclosure statement.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature in these forms.

12. Provide estimates of the hour burden of the collection of information.

The statement should:

Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

There are approximately 55,000 computer‑generated CM‑929 forms sent to all beneficiaries (one each) on a yearly basis to certify and/or correct information reflected in DCMWC's files. We estimate that 87% of 55,000 beneficiaries, or 47,850 who do not have representative payees, will be sent Form CM-929, and the remaining 13%, or 7,150 beneficiaries who have representative payees, will be sent the Form CM-929P. DCMWC experience has been that 90% of all completed Forms CM-929 are essentially certifications. The remaining 10% of completed forms reflect correction of data. DCMWC estimates that the time required of respondents to read the CM‑929 and certify that all benefit information is correct and accurate is five minutes. The time required to read the form and report one or more corrections to the benefit information is no more than eight minutes. Therefore, the estimated total burden to the 55,000 beneficiaries in completing this form is 4,858 burden hours, based on the following:

90% of 55,000 = 49,500 x 5 minutes = 4,125 hours

10% of 55,000 = 5,500 x 8 minutes = 733 hours

4,858 hours

Benefits due a DOL black lung beneficiary may be paid to a representative payee on behalf of the beneficiary when the beneficiary is unable to manage his/her benefits due to incapability, incompetence or minority. The CM-929P form is used to collect expenditure data regarding the disbursement of the beneficiary's benefits by the payee to assure that the beneficiary's needs are being met. This form, CM-929P replaces forms CM-623 and CM-623S in most cases because they will no longer be sent separately. The burden hours for the existing independent OMB 1240-0020 will be reduced by more than the increased burden of the present clearance because some of the information on both forms is similar, and because only one form is involved instead of two, thereby reducing the chance that one of the forms will be lost or misplaced.

In turn, approximately 20% of the respondents to the Representative Payee Report use the short version, CM-623S, which does not require detailed financial information from payees who live in the same household as the beneficiaries. This form is included in the combined CM-929P with a clear instruction for the representative payee to skip over questions that do not apply to his/her situation.

We estimate the burden on respondents who answer the full CM-929P, or about 5,720 payees, to be 80 minutes per form, and we have estimated the burden on respondents who answer the short version to be 6 minutes per form. Therefore, we have calculated the total burden to be 7,769 hours as follows:

80% of 7,150 = 5,720 x 80 minutes = 7,626 hours

20% of 7,150 = 1,430 x 6 minutes = 143 hours

= 7,769 hours

Subtotal Burden Hours for CM-929 = 4,858 hours

Subtotal Burden Hours for CM-929P = 7,769 hours

Total Burden Hours =12,627 hours

We have calculated the average processing time to be 65 minutes for the CM-929P, including the 20% of the forms that take only 6 minutes to complete, and the 80% that take 80 minutes. The total number of burden hours (7,769) has been divided by the total number of forms (7,150) to arrive at an average burden of 65 minutes for each form completed.

There is no monetary cost to the respondent to provide this information; rather, the submission of this information is an intrinsic part of the benefit process. However, to comply with PRA 1995, we used the Federal minimum wage as a representative wage rate to calculate the cost of the burden hours.

12,627 x $7.25 = $91,546.00.

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

There are no technological or system costs associated with the collection of this information. This form is a postage paid self mailer.

14. Provide estimates of annualized cost to the Federal government.

The estimated total cost to the Federal Government for development, printing, mailing and processing the CM-929 and CM-929P is approximately $439,212.00. The cost is computed as follows:

a. Estimated printing cost for 55,000 forms $12,000.00

This includes printing the initial mailing of 55,000 and follow-up printing to 9,500 beneficiaries who do not respond to the first mailing.

55,000 + 9,500 = 64,500.

b. Estimated cost for mailing and returning the form $28,380.00 + $32,450.00 = $60,830.00

This includes follow-up mailings to beneficiaries who do not respond to the first mailing. DCMWC mails approximately 9,500 follow-up forms to beneficiaries.

64,500 x 44¢ = $28,380.00 for out going mail.

44¢ + 5¢ + 10¢ = 59¢ includes cost of return postage, envelope and 10¢ postal surcharge)

55,000 x 59¢ = $32,450.00 for responses.

c. Estimated processing cost $366,382.00

A GS‑12/5 spends an average of 6 minutes evaluating each CM-929 form, 6 minutes evaluating each partially-completed CM-929P, and 30 minutes evaluating each fully-completed CM-929P. A GS‑6/4 spends an average of 3 minutes on clerical duties associated with each form. The FY 2011 Salary Table for the RUS was used to determine Federal cost.

CM-929 55,000 x 6 min = 5,500 hours x $37.37 = $205,535.00

CM-929P(partially completed) 1,430 x 6 min = 143 hours x $37.37 = $ 5,344.00

CM-929P(fully completed) 5,720 x 30 min= 2,860 hours x $37.37 = $106,878.00

Clerical for both 62,150 x 3 min = 3,107 hours x $15.65 = $ 48,625.00

Total $366,382.00

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

The total burden hours have decreased by 2,642 hours, from 15,269 to 12,627. This adjustment reflects a declining population of both Part C and Part B beneficiaries.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This ICR does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement identified in Item "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

There are no exceptions to the certification statement.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

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