Information Collection

Notice Of Employee's Injury Or Death

IC 168438 under ICR 197804-1215-001 · OMB 1215-0063.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0063 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	NOTICE OF EMPLOYEE'S INJURY OR DEATH	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-201				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 240,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	240,000	140,000	100,000
Annual IC Time Burden (Hours)	60,000	10,000	50,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.