CLAIMANT'S STATEMENT

ICR 198402-1215-002

OMB: 1215-0089

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
122128 Migrated
ICR Details
1215-0089 198402-1215-002
Historical Active 198309-1215-034
DOL/ESA
CLAIMANT'S STATEMENT
Revision of a currently approved collection   No
Regular
Approved without change 03/01/1984
Retrieve Notice of Action (NOA) 02/06/1984
THE FORMS CLEARED UNDER 1215-0089 WILL BE EXEMPT FROM THE REQUIREMENT THAT A CURRENT EXPIRATION DATE BE AFFIXED ON ALL FORMS COVERED BY THE PAPERWORK REDUCTION ACT (5 CFR 1320).
  Inventory as of this Action Requested Previously Approved
02/28/1987 02/28/1987 02/28/1984
137,935 0 156,700
64,304 0 94,050
0 0 0

FORMS ARE COMPLETED BY CLAIMANTS AND PHYSICIANS IN SUPPORT OF CLAIMS F COMPENSATION BENEFITS UNDER THE LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT AND RELATED STATUTES.

None
None


No

1
IC Title Form No. Form Name
CLAIMANT'S STATEMENT LS-267,203,, 204, 260,, 262, & 263

  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 137,935 156,700 0 -28 -18,737 0
Annual Time Burden (Hours) 64,304 94,050 0 -45 -29,701 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.
02/06/1984


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