Report of Changes That May Affect Your Black Lung Benefits
1240-0028
December 2017
SUPPORTING STATEMENT
Report of Changes That May Affect Your Black Lung Benefits
1240-0028
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 Black Lung Benefits Act, 30 USC 901 et seq., including 30 USC 936 and 941, and its implementing regulations, 20 CFR 725.533(e), authorizes the Division of Coal Mine Workers’ Compensation (DCMWC) to collect information regarding compensation payments to coal miners and other 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 https://www.dol.gov/owcp/dcmwc/pl107-275.pdf, 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 DCMWC‘s 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.
The CM-929P is sent to all beneficiaries that have a representative payee. Compensation is 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 is printed by the 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 benefits. Additionally, representative payees are requested to provide information regarding the use of benefits received, where the beneficiary lives, and ensuring the needs of the beneficiary are being met. The representative payee reviews the information specific to the beneficiary, as well as provides their accounting of the funds received, and certifies that all information is current or provides updated information. Collection of this information is authorized by 20 CFR 725.513(a). The form includes a warning about potential consequences of failure to report changes as described in 30 USC 922 and 20 CFR 725.513.
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 and CM-929P are both 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. The CM-929P is completed by representative payees for primary beneficiaries to report the same factors that may affect the beneficiaries’ benefits. Representative payees also provide information on the beneficiary’s location and certify that benefits are used for the needs of the beneficiary, including an annual accounting when necessary. Both forms request completion upon receipt. The claims staff 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 staff 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) https://ocio.nih.gov/ITGovPolicy/Documents/Paperwork_Elimination_Act_Public_Law_105-277.pdf, the forms in this information collection were considered, but found not to be practicable for electronic submission. For the CM-929, the respondents are of a variety of demographics and generally include retired, disabled coal mine workers and elderly spouses. Given these demographics, it is unlikely that any significant proportion would have access to the electronic option. Although individuals completing the CM-929P may not be similarly limited, the number of these filings is comparatively low (i.e., on 13% of total annual CM-929 and CM-929P filings). Thus, 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. 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/dcmwc/regs/compliance/blforms.htm in case claimants misplace the partially completed one that is sent to them. The CM-929 and CM-929p are also 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 A.2 above.
No other agency collects this information. Forms 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 of information impacts small businesses or other small entities, 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 and lack of knowledge of whether benefits are being appropriately used for beneficiaries.
7. Explain any special circumstance required in the conduct of the information collection:
There are no special circumstances for 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.
A Federal Register Notice inviting public comment was published on October 13, 2017(82 FR 47773). No comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payments or gifts are made to respondents to furnish the information. However, the beneficiary-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.
Forms CM-929 and CM-929P includes a Privacy Act Notice (PAN) explaining that information will be used to determine eligibility for and the amount of benefits payable. The PAN also explains that the information may be used by other agencies or persons in handling matters relating to the subject matter of the claim. This information is included in a System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished.
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.
This collection contains no questions of a sensitive nature.
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.
There are approximately 26,000 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 26,000 beneficiaries, or 22,620, will be sent Form CM-929 only, and the remaining 13%, or 3,380, will be sent 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 26,000 beneficiaries in completing this form is 6,089 burden hours, based on the following:
90% of 22,620 = 20,358 x 5 minutes = 1,697 hours
10% of 22,620 = 2,262 x 8 minutes = 302 hours
1,999 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.
The CM-929P includes clear instructions 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 3,042 (90%) payees, to be 80 minutes per form, and we have estimated the burden on 338 (10%) respondents who answer the short version to be 6 minutes per form. Therefore, we have calculated the total burden to be 4,090 hours as follows:
90% of 3,380 = 3,042 x 80 minutes = 4,056 hours
10% of 3,380 = 338 x 6 minutes = 34 hours
= 4,090 hours
Subtotal Burden Hours for CM-929 = 1,999 hours
Subtotal Burden Hours for CM-929P = 4,090 hours
Total Burden Hours = 6,089 hours
We have calculated the average processing time to be 65 minutes for the CM-929P, including the 10% of the forms that take only 6 minutes to complete, and the 90% that take 80 minutes. The total number of burden hours (4,090) has been divided by the total number of forms (3,380) 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 https://www.gpo.gov/fdsys/pkg/PLAW-104publ13/html/PLAW-104publ13.htm, we used the Federal minimum wage https://www.dol.gov/whd/minimumwage.htm as a representative wage rate to calculate the cost of the burden hours.
6,089 x $7.25 = $44,145.25.
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 $212,024.03. The cost is computed as follows:
a. Estimated printing cost for 26,000 forms = $5,800.00
This includes printing the initial mailing of 26,000 and follow-up printing to 4,420 beneficiaries who do not respond to the first mailing.
26,000 + 4,420 = 30,420
b. Estimated cost for mailing and returning the form $14,905.80 + $16,640.00 = $31,545.80
This includes follow-up mailings to beneficiaries who do not respond to the first mailing. DCMWC mails approximately 4,420 follow-up forms to beneficiaries.
30,420 (26,000 + 4,420) x 49¢ = $14,905.80 for outgoing mail.
49¢ + 5¢ + 10¢ = 64¢ includes cost of return postage, envelope and 10¢ postal surcharge)
26,000 x 64¢ = $16,640.00 for responses.
c. Estimated processing cost $174,678.23
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 response. The FY 2017 Salary Table for the RUS was used to determine Federal cost. https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/RUS_h.pdf
CM-929
22,620 x 6 min = 2,262 hours x $39.19 = $88,647.78
CM-929P(partially completed)
338 x 6 min = 34 hours x $39.19 = $1,332.46
CM-929P(fully completed)
3,042 x 30 min= 1,521 hours x $39.19 = $59,607.99
Clerical for both
26,000 x 3 min = 1,300 hours x $19.30 = $25,090.00
Total $174,678.23
15. Explain the reasons for any program changes or adjustments reported.
The total burden hours have decreased by 1,029 hours, from 7,118 to 6,089. This adjustment reflects a declining population of both Part C and Part B beneficiaries.
The following minor changes have been made to CM-929 and CM-929P:
CM-929 (Page 2 of Instructions) – renamed “Paperwork/Privacy Act Notice” to Privacy Act Notice
CM-929 (Page 2 of Instructions) - Updated language of Privacy Act Notice
CM-929 (Page 1 of Form) – renamed “Case ID” to DOL’s Case ID Number
CM-929 (Page 1 of Form) – added “address” to Item 2
CM-929P (Page 2 of Instructions) – renamed “Paperwork/Privacy Act Notice” to Privacy Act Notice
CM-929P (Page 2 of Instructions) - Updated language of Privacy Act Notice
CM-929P (Page 1 of Form) – renamed “Case ID” to DOL’s Case ID Number
CM-929P (Page 1 of Form) – added “address” to Item 2
CM-929P (Page 3 of Form) - renamed “Case ID” to DOL’s Case ID
CM-929P (Page 4 of Form) – Item 22, updated the certification statement to include warning of misuse of benefits.
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 ROCIS.
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.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | Charles Lloyd |
| Last Modified By | SYSTEM |
| File Modified | 2017-12-14 |
| File Created | 2017-12-14 |