Information Collection

Request for Examination and/or Treatment

IC 13713 under ICR 201003-1240-029 · OMB 1240-0029.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0029 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-1 Request for Examination and/or Treatment	Form
LS-1 Request for Examination and/or Treatment ls-1.pdf www.dol.gov/esa/dlhwc/lsforms.htm	Form

IC Title:

Request for Examination and/or Treatment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.419

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-1	Request for Examination and/or Treatment	ls-1.pdf	http://www.dol.gov/esa/dlhwc/lsforms.htm	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title: DOL/GOVT-15

FR Citation: 58 FR 49599

Number of Respondents: 25,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	75,000	-26,250	101,250
Annual IC Time Burden (Hours)	81,000	-28,350	109,350
Annual IC Cost Burden (Dollars)	3,558,000	3,517,000	41,000

Documents for IC

table that charts IC Documents
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.