REQUEST FOR EXAMINATION AND/OR TREATMENT

ICR 198309-1215-029

OMB: 1215-0066

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
168445 Migrated
ICR Details
1215-0066 198309-1215-029
Historical Active 197811-1215-004
DOL/ESA
REQUEST FOR EXAMINATION AND/OR TREATMENT
No material or nonsubstantive change to a currently approved collection   No
Emergency 09/06/1983
Approved with change 09/06/1983
Retrieve Notice of Action (NOA) 09/06/1983
  Inventory as of this Action Requested Previously Approved
12/31/1983 12/31/1983 12/31/1983
200,000 0 200,000
100,334 0 66,667
0 0 0

REPORT AUTHORIZES THE MEDICAL CARE FOR AN EMPLOYEE COVERED UNDER THE LONGSHORE ACT. THE EMPLOYER/INSURANCE CARRIERS ARE RESPONSIBLE FOR ARRANGING MEDICAL CARE. THE LS-1 IS THE VEHICLE USED WHEN AUTHORIZING THIS TYPE OF CARE. THE REPORT IS ALSO USED TO PROVIDE INFORMATION TO LHWC FROM TREATING PHYSICIANS.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR EXAMINATION AND/OR TREATMENT LS-1

  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 200,000 200,000 0 0 0 0
Annual Time Burden (Hours) 100,334 66,667 0 -9,333 43,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
09/06/1983


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