Miner’s Claim for Benefits Under the Black Lung Benefits Act and Employment History
1240-0038
May 2018
SUPPORTING STATEMENT
Miner's Claim for Benefits under the Black Lung Benefits Act and Employment History
1240-0038
This ICR seeks to reinstate a previously approved collection with changes. The changes clarify certain questions and disclosures. These are more fully discussed in item 15 of this supporting statement.
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.
CM‑911
The Black Lung Benefits Act (BLBA), 30 USC 901 et seq., provides monthly disability benefits to coal miners who are totally disabled due to pneumoconiosis (black lung disease) and to certain survivors of miners. Miners entitled to benefits also receive medical benefits for treatment related to their pneumoconiosis and resulting disability.
A miner who applies for black lung benefits must complete the CM‑911 (application form). The completed form gives basic identifying information about the applicant and is the beginning of the development of the black lung claim. Regulations 20 CFR 725.304a authorizes this information collection.
CM‑911a
An applicant filing for black lung benefits must complete a CM‑911a at the same time the black lung application form is submitted. This form, when completed, provides a complete history of the miner’s employment and helps to establish whether the individual currently or formerly worked in the nation's coal mines and how long that employment lasted. Title 20 CFR 725.404(a) authorizes this information collection.
The collection of the coal miner’s Social Security Number (SSN) is necessary because of offset provisions in the laws for both the Social Security Administration and the BLBA to prevent overpayments and duplicate benefits. The Division of Coal Mine Workers’ Compensation does not list the SSN on outgoing correspondence, but rather uses a computer generated DOL Case ID Number.
The SSN is also needed to coordinate medical treatment benefits between the Black Lung Program and other health care insurers to prevent duplicate reimbursement. Because the universal billing form (CMS-1500) and DCMWC’s version (OWCP-1500) both use the SSN, it would be almost impossible to properly pay medical providers for treatment services given to disabled miners without it.
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.
CM‑911
Upon completion by the applicant and receipt of the CM‑911 by the Black Lung District Office, the claims staff reviews the information and begins the verification process of each item on the application. For example, the claims staff requests copies of the birth and marriage records to establish dependency and to help determine the potential amount of benefits to which the miner would be entitled. Upon receipt and verification of all items requested, the claims staff can determine if the applicant meets the statutory criteria for an award of benefits. If this information were not collected and the miner's signature were not obtained on the CM‑911, the requirements of the Black Lung Benefits Act would not be met.
CM‑911a
Once the CM‑911a is completed and received in the black lung office, the claims staff reviews and verifies the information to determine if coal mine employment is established. Other types of employment are also reviewed to help establish total disability due to coal mine employment. Proof of coal mine employment is a major element in establishing a causal relationship between employment and total disability due to pneumoconiosis for entitlement purposes. If this information were not gathered, neither coal mine employment nor the length of that employment could be established.
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.
Both forms can be filled out on-screen, printed, and mailed or may be printed, completed by hand, and mailed. However, they have not been made available for electronic submission. Each form requires the signature of the claimant, which could be affixed electronically, but also contains a space for the signatures of two witnesses if the claimant is unable to sign his or her name. Three independently-obtained digital signatures by different people would be required to submit such a form on-line and, in order to keep claim information confidential, the Department of Labor’s website does not permit forwarding or submission of on-line forms to any place other than the Department’s designated electronic mailbox. This would prevent the claimant from forwarding the form to the witness after both had received their digital signature verification keys.
These forms are available for downloading at: http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm.
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.
There is no similar information available.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
This information is provided by individuals; thus, its collection does not impact 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.
This information is collected only at the time of application. If it were collected less frequently, this information would not be available for case adjudication.
7. Explain any special circumstance required in the conduct of this 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 27 December 2017 (82FR61334). No public 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 any gifts or payments to furnish the requested information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
Since the completed forms are maintained in the claimant’s case file, the information collected is covered by the Privacy Act System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished. The Privacy Act notice on the forms let users know under what circumstances information may be released.
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. Provide estimates of the hour burden of the collection of information.
CM‑911
The estimated burden of this information collection is approximately 3,690 hours. This burden is based on a submission of 4,920 CM‑911's with 45 minutes to read and complete the form. Local Social Security Offices or Black Lung Offices supply the form and help the claimant complete the form.
45 minutes x 4,920 forms = 3,690 total burden hours.
For the burden cost to the applicant, we use the 2018 Federal minimum wage of $7.25 per hour. https://www.minimum-wage.org/federal
3,690 burden hours x $7.25 per hour = $26,752.50
CM‑911a
The estimated burden of this information collection is approximately 3,280 hours. This burden is based on a submission of 4,920 CM‑911a's with 40 minutes to read and complete the form. Local Social Security Offices or Black Lung Offices supply the form and help the claimant complete the form.
40 minutes x 4,920 forms = 3,280 total burden hours.
For the burden cost to the applicant, we use the 2017 Federal minimum wage of $7.25 per hour. https://www.minimum-wage.org/federal
3,280 burden hours x $7.25 per hour = $23,780.00.
Total Time Burden:
9,840 Respondents
9,840 Responses
6,970 Hours (3,960 CM-911 and 3,280 CM-911a)
Annual Costs to Respondents (capital/start-up & operation and maintenance).
Since the CM-911 and the CM-911a are generally completed and returned at the same time, no additional mailing costs appear for the CM-911. An estimated 70% (4,920 X 70% = 3,444) of the respondents mail their response, and the cost is estimated at 52 cents per respondent for postage and envelope. The remaining 30% of respondents provide their information at local offices. The estimated cost for operations and maintenance has decreased from $2,058.00 to $1,790.88 due to fewer filings. The total respondent cost is $1,790.88. The cost is figured as follows:
CM-911: no cost since both forms are returned together
CM-911a: 3,444 x .52 (.49 postage + .3 envelope) = $1,790.88
14. Provide estimates of annualized cost to the Federal government.
CM‑911
The estimated total cost to the Federal Government for 4,920 CM‑911's is approximately $98,031.
a. Estimated mailing cost: None - Forms obtained from Black Lung or Social Security District Office.
b. Estimated processing cost: $98,031.
GS‑12/5 spends about 30 minutes per form for review
$39.85 x .50 x 4,920 = $98,031 (GS-12/5 RUS salary from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/RUS_h.pdf.
CM‑911a
The estimated total cost to the Federal government for 4,920 CM‑911a's is approximately $99,310.
a. Estimated mailing cost: $1,279.
Since the CM-911 and the CM-911a are mailed at the same time, no additional mailing costs appear for the CM-911. An estimated 50% (2,460) of the CM-911 and CM-911a are sent to the black lung applicants, and the cost is estimated at 52 cents per applicant for postage and envelope. The total mailing cost is $1,279.20. The cost is figured as follows:
CM-911: no cost since both forms are mailed together
b. Estimated processing cost: $98,031.
GS‑12/5 spends about 30 minutes per form for review
$39.85 x .50 x 4,920 = $98,031.
The total Federal cost is $197,341. ($98,031 CM-911 + $99,310 CM-911a).
15. Explain the reasons for any program changes or adjustments.
The annual number of responses decreased by 1,160 from 11,000 to 9,840. This decrease is a result of fewer claims filed.
The following updates were made to the forms:
CM-911
7.a. updated;
8. updated;
10.d. updated to request copy of state workers’ compensation award;
10. e, h, i added “stat”;
16. added two statements: “If there are no children who fit these categories, skip to 17.” And “List all children who fall into one of the following categories” “List all such children.”;
17. added “Important Notice” as a header;
17. added “state” before “workers’ compensation” and “Failure to report events promptly could result in an overpayment requiring repayment.”;
20. Updated certification statement located after Item 20 and before Item 21. Added “under 30 USC 941” and “subject to a”. Removed “thereof shall be punished by a”;
Updated Privacy Act Notice;
Updated Computer Matching Program language; and
Updated Notice – replaced “examiner” with “staff”
CM-911a
Page 1, below “Miner’s Name” added “List all coal mine and non-coal mine employment. Start with most recent first.”;
Page 2, above certification statement, added “If additional room is needed, please attach a separate sheet.”;
Page 2, paragraph located before Item 6. Added “under 30 USC 941”, “or payment”, and “subject to”. Removed “thereof shall be punished by”;
Page 2, updated Privacy Act Notice; Removed “in the report”, added “for the amount of benefits payable”, “you furnish this on the form”, “Government”, and “including potentially liable coal mine operators and their insurance carriers; contractors providing automated data processing services to the Department of Labor; representative of the parties to the claim; and federal, state or local agencies in obtaining information about eligibility for benefits”. Removed “any”, added “(5) 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”;
Page 2, Notice – changed “examiner” to “staff.”
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.
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 | US Department of Labor |
| Last Modified By | SYSTEM |
| File Modified | 2018-05-17 |
| File Created | 2018-05-17 |