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 201003-1240-003 · OMB 1240-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0003 can be found here:

Documents and Forms

Document Name Document Type
Form LS-210 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 Form
LS-202 Employer's Firt Report of Injury or Occupational Illness ls-202.pdf www.dol.gov/esa/owcp/dlhwc/ls-202.pdf Form
LS-210 Employer's Supplementary Report of Accident or Occupatio ls-210.pdf www.dol.gov.gov/esa/owcp/dlhwc/ls-210.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 702.407 20 CFR 702.202 20 CFR 702.201

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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
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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DLO/ESA-15	FR Citation: 58 FR 49599

Number of Respondents: 26,381	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 1 %

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

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.