03-25109. Submission for OMB Review; Comment Request

September 17, 2003.

The Department of Labor (DOL) has submitted the following public information collection requests (ICRs) to the Office of Management and Budget (OMB) for review and approval in accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13, 44 U.S.C. chapter 35). A copy of each ICR, with applicable supporting documentation, may be obtained by calling the Department of Labor. To obtain documentation, contact Darrin King on 202-693-4129 (this is not a toll-free number) or e-mail: [e-mail].

Comments should be sent to Office of Information and Regulatory Affairs, Attn: OMB Desk Officer for the Employment Standards Administration (ESA), Office of Management and Budget, Room 10235, Washington, DC 20503 (202-395-7316/this is not a toll-free number), within 30 days from the date of this publication in the Federal Register.

The OMB is particularly interested in comments which:

• Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility;
• Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used;
• Enhance the quality, utility, and clarity of the information to be collected; and
• Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.

Type of Review: Extension of a currently approved collection.

Agency: Employment Standards Administration.

Title: Health Insurance Claim Form.

OMB Number: 1215-0055.

Affected Public: Business or other for-profit; Not-for-profit institutions; and Individuals or households.

Frequency: On occasion.

Number of Respondents: 533,427.

Number of Annual Responses: 2,133,708.

Estimated Time Per Response: 7 minutes.

Total Burden Hours: 248,812.

Total Annualized Capital/Startup Costs: $0.

Total Annual Costs (operating/maintaining systems or purchasing services): $0.

Description: The information collected by the Form OWCP-1500 is required to reimburse health care providers for services rendered to injured employees covered under the Federal Employees' Compensation Act, 5 U.S.C. 8101 et seq., the Black Lung Benefits Act, 30 U.S.C. 901 et seq., and the Energy Employees Occupational Illness Compensation Program Act of 2000 42 U.S.C. 7384 et seq. Appropriate reimbursement cannot be made without documentation that details services provided by health care professionals throughout the country.

Type of Review: Extension of a currently approved collection.

Agency: Employment Standards Agency.

Title: Authorization for Release of Medical Information.

OMB Number: 1215-0057.

Affected Public: Individuals or households.

Frequency: One time.

Number of Respondents: 1,500.

Number of Annual Responses: 1,500.

Estimated Time Per Response: 5 minutes.

Total Burden Hours: 125.

Total Annualized Capital/Startup Costs: $0.

Total Annual Costs (operating/maintaining systems or purchasing services): $0.

Description: The Black Lung Benefits Act, as amended, 30 U.S.C. 901 et seq., and 20 CFR 725.405 require that all relevant medical evidence be considered before a decision can be made regarding a claimant's eligibility for benefits. The CM-936 is a form that gives the claimant's consent for release of information required by the Privacy Act of 1974, and contains information required by medical institutions and private physicians to enable them to release pertinent medical information.

Ira L. Mills,

Department Clearance Officer.