Request for Medical Reports

ICR 199704-1215-004

OMB: 1215-0106

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
13774 Migrated
ICR Details
1215-0106 199704-1215-004
Historical Active 199405-1215-001
DOL/ESA
Request for Medical Reports
Extension without change of a currently approved collection   No
Regular
Approved without change 06/16/1997
Retrieve Notice of Action (NOA) 04/25/1997
Approved; DOL addendum of 6/10/97.
  Inventory as of this Action Requested Previously Approved
06/30/2000 06/30/2000 06/30/1997
2,520 0 2,520
1,260 0 1,260
0 0 0

Medical reports are used by the Longshore and Harbor Worker's Compensation Act Program to support injured workers' claims for compensation benefits under section 7 of the Longshore Act (33 U.S.C. 901 et seq.), as amended and extended.

None
None


No

1
IC Title Form No. Form Name
Request for Medical Reports LS-158, LS-415, LS-525

  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 2,520 2,520 0 0 0 0
Annual Time Burden (Hours) 1,260 1,260 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.
04/25/1997


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