Request for Examination and/or Treatment

ICR 200801-1215-001

OMB: 1215-0066

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2008-04-17
Supplementary Document
2008-01-08
Supplementary Document
2008-01-08
Supplementary Document
2008-01-08
IC Document Collections
IC ID
Document
Title
Status
13713 Modified
ICR Details
1215-0066 200801-1215-001
Historical Active 200505-1215-002
DOL/ESA
Request for Examination and/or Treatment
Extension without change of a currently approved collection   No
Regular
Approved without change 05/28/2008
Retrieve Notice of Action (NOA) 04/25/2008
  Inventory as of this Action Requested Previously Approved
05/31/2011 36 Months From Approved 07/31/2008
75,000 0 101,250
81,000 0 109,350
3,558,000 0 41,000

The LS-1 is used by employers to authorize medical treatment for injured workers and by physicians to report findings of physical examinations and treatment recommended.

US Code: 33 USC Chapter 18, Section 907 Name of Law: Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  73 FR 2947 01/16/2008
73 FR 22432 04/25/2008
No

1
IC Title Form No. Form Name
Request for Examination and/or Treatment LS-1 Request for Examination and/or Treatment

  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 75,000 101,250 0 0 -26,250 0
Annual Time Burden (Hours) 81,000 109,350 0 0 -28,350 0
Annual Cost Burden (Dollars) 3,558,000 41,000 0 0 3,517,000 0
No
No
Burden has been reduced by 28,350 hours (109,350 previous burden hours – 81,000 current burden hours = 28,350 hours). This reduction in burden hours is the result of reduced reporting under the Act resulting in a reduction in the number of responses from the previous estimate of 101,250 responses to the current estimate of 75,000. A cost to the employer of $47.00 is applied per response for the physician’s time in performing each exam and completing the form. This cost, which was not accounted for in the last submission, has increased the cost burden by $3,525,000. Netted against a reduction in mailing cost of $8,000 due to fewer responses, the cost burden has increased by $3,517,000.

$65,700
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Cheryl Jordan 202 693-0289 [email protected]

  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.
04/25/2008


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