Agency Information Collection Activities; Submission for OMB Review; Comment Request; Certificate of Medical Necessity


The Department of Labor (DOL) is submitting the Office of Workers' Compensation Programs (OWCP) sponsored information collection request (ICR) titled, “Certificate of Medical Necessity,” as revised, (Form CM-893) to the Office of Management and Budget (OMB) for review and approval for use in accordance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501et seq.).


Submit comments on or before November 30, 2011.


A copy of this ICR with applicable supporting documentation; including a description of the likely respondents, proposed frequency of response, and estimated total burden may be obtained from the Web site,, on November 1, 2011, or by contacting Michel Smyth by telephone at (202) 693-4129 (this is not a toll-free number) or sending an email to

Submit comments about this request to the Office of Information and Regulatory Affairs, Attn: OMB Desk Officer for the Department of Labor, Office of Workers' Compensation Programs (OWCP), Office of Management and Budget, Room 10235, Washington, DC 20503, Telephone:(202) 395-6929/Fax:(202) 395-6881 (these are not toll-free numbers), email:

For further information contact:

Contact Michel Smyth by telephone at (202) 693-4129 (this is not a toll-free number) or by email at

Supplementary information:

On October 31, 2011, the DOL is submitting the revised Certificate of Medical Necessity ICR to the OMB for review and approval for use in accordance with the PRA (44 U.S.C. 3501et seq.). The Certificate of Medical Necessity is completed by a coal miner's physician and is used by the OWCP to determine whether the miner meets impairment standards to qualify for durable medical equipment, home nursing, and/or pulmonary rehabilitation. The OWCP is revising this information collection to make cosmetic changes to the form, technically making this submission a revision under the PRA; however, the changes are not expected to alter the public burden.

This information collection is subject to the PRA. A Federal agency generally cannot conduct or sponsor a collection of information, and the public is generally not required to respond to an information collection, unless it is approved by the OMB under the PRA and displays a currently valid OMB Control Number. In addition, notwithstanding any other provisions of law, no person shall generally be subject to penalty for failing to comply with a collection of information if the collection of information does not display a valid OMB Control Number. See5 CFR 1320.5(a) and 1320.6. The DOL obtains OMB approval for this information collection under OMB Control Number 1240-0024. The current OMB approval is scheduled to expire on October 31, 2011; however, it should be noted that information collection information collection requirements submitted to the OMB receive a month-to-month extension while they undergo review. For additional information, see the related notice published in the Federal Register on August 30, 2011 (76 FR 53966).

Interested parties are encouraged to send comments to the OMB, Office of Information and Regulatory Affairs at the address shown in the ADDRESSES section within 30 days of publication of this notice in the Federal Register. In order to help ensure appropriate consideration, comments should reference OMB Control Number 1240-0024. The OMB is particularly interested in comments that:

• 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.

Agency: Office of Workers' Compensation Programs (OWCP).

Title of Collection: Certificate of Medical Necessity.

OMB Control Number:1240-0024.

Affected Public: Private Sector—Businesses or other for-profits and Not-for-profit institutions.

Total Estimated Number of Respondents:2,500.

Total Estimated Number of Responses:2,500.

Total Estimated Annual Burden Hours:965.

Total Estimated Annual Other Costs Burden:$1,335.

Dated: October 25, 2011. Michel Smyth,

Departmental Clearance Officer.


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