Employer's First Report of Injury or Occupational Disease; Physician's Report on Impairment of Vision; and Employer's Supplementary Report of Accident or Occupational Illness

ICR 200408-1215-001

OMB: 1215-0031

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0031 200408-1215-001
Historical Active 200107-1215-001
DOL/ESA
Employer's First Report of Injury or Occupational Disease; Physician's Report on Impairment of Vision; and Employer's Supplementary Report of Accident or Occupational Illness
Extension without change of a currently approved collection   No
Regular
Approved without change 10/08/2004
Retrieve Notice of Action (NOA) 08/12/2004
  Inventory as of this Action Requested Previously Approved
10/31/2007 10/31/2007 10/31/2004
23,220 0 26,660
5,835 0 6,705
10,000 0 11,000

These forms are used to report injuries, periods of disability, and medical treatment under the Longshore and Harbor Workers' Compensation Act.

None
None


No

  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 23,220 26,660 0 0 -3,440 0
Annual Time Burden (Hours) 5,835 6,705 0 0 -870 0
Annual Cost Burden (Dollars) 10,000 11,000 0 0 -1,000 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.
08/12/2004


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