Description of Coal Mine Work and Other Employment

Forms and Documents

Document Name	Status
Form CM-913 Description of Coal Mine Work and Other Employment Form	Modified
SS 1240-0035 CM-913 2023_OCIO1-MM.docx Supporting Statement A	2023-09-07
DOL-OWCP-9.pdf Supplementary Document	2020-03-04
DOL-OWCP-2.pdf Supplementary Document	2020-03-04
725.405b.pdf Supplementary Document	2020-03-04
20 CFR 718.204.doc Supplementary Document	2007-09-14

IC Document Collections

IC ID	Document Title	Status
13691	Description of Coal Mine Work and Other Employment Form	Modified

ICR Details

OMB Control No: 1240-0035	ICR Reference No: 202304-1240-006
Status: Received in OIRA	Previous ICR Reference No: 202003-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Description of Coal Mine Work and Other Employment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/13/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2023
Responses	4,710	6,100
Time Burden (Hours)	2,355	3,050
Cost Burden (Dollars)	2,600	3,515

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Abstract: The Description of Coal Mine Work and Other Employment (Form CM-913) is used to compare non-coal mine work to coal mine work.

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Authorizing Statute(s): US Code: 30 USC 901-945 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 29952	05/09/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 62820	09/13/2023
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Description of Coal Mine Work and Other Employment	CM-913	Description of Coal Mine Work and Other Employment

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ICR Summary of Burden

	Total Request	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	4,710	6,100	0	-1,390	0	0
Annual Time Burden (Hours)	2,355	3,050	0	-695	0	0
Annual Cost Burden (Dollars)	2,600	3,515	0	-915	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of respondents decreased from 6,100 to 4,710. The number of respondents decreased due to a decrease of claims field.

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Annual Cost to Federal Government: $56,073

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

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Common Form ICR:  No

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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: 09/13/2023

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