Request for Examination and/or Treatment

ICR 199909-1215-001

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
13711 Migrated
ICR Details
1215-0066 199909-1215-001
Historical Active 199610-1215-001
DOL/ESA
Request for Examination and/or Treatment
Extension without change of a currently approved collection   No
Regular
Approved without change 11/22/1999
Retrieve Notice of Action (NOA) 09/23/1999
Approved consistent with clarification in DOL memo of 11-2-99.
  Inventory as of this Action Requested Previously Approved
11/30/2002 11/30/2002 11/30/1999
115,500 0 132,000
124,740 0 142,560
42,000 0 46,000

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 115,500 132,000 0 0 -16,500 0
Annual Time Burden (Hours) 124,740 142,560 0 0 -17,820 0
Annual Cost Burden (Dollars) 42,000 46,000 0 0 -4,000 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.
09/23/1999


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