OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act

IC 43808 under ICR 200901-1215-002 · OMB 1215-0160.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form LS-201 proposed
Notice of Employee's Injury or Death Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-513 proposed
Report of Payments Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-267 proposed
Claimant's Statement Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-203 proposed
Employee's Claim for Compensation Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-262 proposed
Claim for Death Benefits Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-271 proposed
Application for Self-Insurance Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-204 proposed
Attending Physician's Supplementary Report Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-274 proposed
Report of Injury Experience of Insurance Carrier or Self-Insured Employer Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
Form LS-200 proposed
Report of Earnings Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form
ESA 100.doc Other-Recordkeeping
LS-201 proposed Notice of Employee's Injury or Death
LS-201 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/ls-201.pdf 		Form
LS-513 proposed Report of Payments
LS-513 proposed.pdf 		Form
LS-267 proposed Claimant's Statement
LS-267 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/LS-267.pdf 		Form
LS-203 proposed Employee's Claim for Compensation
LS-203 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/ls-203.pdf 		Form
LS-262 proposed Claim for Death Benefits
LS-262 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/ls-262.pdf 		Form
LS-271 proposed Application for Self-Insurance
LS-271 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/LS-271.pdf 		Form
LS-204 proposed Attending Physician's Supplementary Report
ls-204 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/ls-204.pdf 		Form
LS-274 proposed Report of Injury Experience of Insurance Carrier or Self
ls-274 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/LS-274.pdf 		Form
LS-200 proposed Report of Earnings
ls-200 proposed.pdf
www.dol.gov/esa/owcp/dlhwc/ls-200.pdf 		Form

Information Collection (IC) Details

View Information Collection (IC)

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Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-201 proposed http://www.dol.gov/esa/owcp/dlhwc/ls-201.pdf Yes No Fillable Printable
Form LS-513 proposed No   Paper Only
Form LS-267 proposed http://www.dol.gov/esa/owcp/dlhwc/LS-267.pdf Yes No Printable Only
Form LS-203 proposed http://www.dol.gov/esa/owcp/dlhwc/ls-203.pdf Yes No Fillable Printable
Form LS-262 proposed http://www.dol.gov/esa/owcp/dlhwc/ls-262.pdf Yes No Fillable Printable
Other-Recordkeeping No   Paper Only
Form LS-271 proposed http://www.dol.gov/esa/owcp/dlhwc/LS-271.pdf Yes No Fillable Printable
Form LS-204 proposed http://www.dol.gov/esa/owcp/dlhwc/ls-204.pdf Yes No Fillable Printable
Form LS-274 proposed http://www.dol.gov/esa/owcp/dlhwc/LS-274.pdf Yes No Fillable Printable
Form LS-200 proposed http://www.dol.gov/esa/owcp/dlhwc/ls-200.pdf Yes No Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 175,374 0 0 -6,694 0 182,068
Annual IC Time Burden (Hours) 66,544 0 0 -4,832 0 71,376
Annual IC Cost Burden (Dollars) 66,587 0 0 1,587 0 65,000

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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