REQUEST FOR EXAMINATION AND/OR TREATMENT

ICR 198311-1215-001

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
122035 Migrated
ICR Details
1215-0066 198311-1215-001
Historical Active 198309-1215-029
DOL/ESA
REQUEST FOR EXAMINATION AND/OR TREATMENT
Revision of a currently approved collection   No
Regular
Approved without change 11/14/1983
Retrieve Notice of Action (NOA) 11/04/1983
  Inventory as of this Action Requested Previously Approved
11/30/1986 11/30/1986 12/31/1983
165,000 0 200,000
95,700 0 100,334
0 0 0

FORM IS USED BY EMPLOYERS TO AUTHORIZE MEDICAL TREATMENT FOR INJURED WORKERS AND BY PHYSICIANS TO REPORT THE FINDINGS OF PHYSICAL EXAMINATIONS AND TREATMENT RECOMMENDED.

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 165,000 200,000 0 -132,704 97,704 0
Annual Time Burden (Hours) 95,700 100,334 0 -17,570 12,936 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.
11/04/1983


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