NOTICE OF EMPLOYEE'S INJURY OR DEATH

ICR 197811-1215-005

OMB: 1215-0063

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
122023 Migrated
ICR Details
1215-0063 197811-1215-005
Historical Active 197806-1215-017
DOL/ESA
NOTICE OF EMPLOYEE'S INJURY OR DEATH
Extension without change of a currently approved collection   No
Regular
Approved without change 12/06/1978
Retrieve Notice of Action (NOA) 11/29/1978
  Inventory as of this Action Requested Previously Approved
12/31/1983 12/31/1983 12/31/1978
240,000 0 100,000
60,000 0 50,000
0 0 0

REPORT IS USED TO NOTIFY THE DEPUTY COMMISSIONER OF THE DEATH OF ANY EMPLOYEE OR BENEFICIARY COVERED UNDER THE LHWC ACT (PL 92-576,

None
None


No

1
IC Title Form No. Form Name
NOTICE OF EMPLOYEE'S INJURY OR DEATH LS-201

  Total Approved 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 240,000 100,000 0 0 140,000 0
Annual Time Burden (Hours) 60,000 50,000 0 0 10,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/29/1978


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