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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 13653 under ICR 200703-1215-005 · OMB 1215-0031.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

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
 
No Modified
 
Mandatory
 
20 CFR 702.407 20 CFR 702.202 20 CFR 702.201

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-202 Employer's Firt Report of Injury or Occupational Illness ls-202.pdf http://www.dol.gov/esa/owcp/dlhwc/ls-202.pdf Yes Yes Fillable Fileable
Form LS-210 Employer's Supplementary Report of Accident or Occupational Illness ls-210.pdf http://www.dol.gov.gov/esa/owcp/dlhwc/ls-210.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

DLO/ESA-15  58 FR 49599

26,381 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   1 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 26,381 0 -60 3,221 0 23,220
Annual IC Time Burden (Hours) 6,595 0 -45 805 0 5,835
Annual IC Cost Burden (Dollars) 11,608 0 0 1,608 0 10,000

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