REQUEST FOR EXAMINATION AND/OR TREATMENT

ICR 198904-1215-017

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
168446 Migrated
ICR Details
1215-0066 198904-1215-017
Historical Active 198610-1215-007
DOL/ESA
REQUEST FOR EXAMINATION AND/OR TREATMENT
No material or nonsubstantive change to a currently approved collection   No
Emergency 04/18/1989
Approved with change 04/18/1989
Retrieve Notice of Action (NOA) 04/18/1989
  Inventory as of this Action Requested Previously Approved
12/31/1989 12/31/1989 12/31/1989
165,000 0 165,000
178,200 0 178,200
0 0 0

FORM IS USED BY EMPLOYERS TO AUTHORIZE MEDICAL TREATMENT FOR INJURED WORKERS AND BY PHYSICIANS TO REPORT 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 165,000 165,000 0 0 0 0
Annual Time Burden (Hours) 178,200 178,200 0 0 0 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.
04/18/1989


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