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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
WORKSHEET FOR OMB NO 1240-0014 March 2012.docx	Supplementary Document	Uploaded 2012-05-22	Available
OMB - Supporting Statement for 1240-0014[1].docx	Supporting Statement A	Uploaded 2012-06-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Other-Recordkeeping	Modified

ICR Details

OMB Control No: 1240-0014	ICR Reference No: 201202-1240-003
Status: Historical Active	Previous ICR Reference No: 201003-1240-014
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/07/2012
	Date Received in OIRA: 06/29/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	08/31/2012
Responses	130,036	0	175,374
Time Burden (Hours)	44,950	0	66,544
Cost Burden (Dollars)	45,979	0	66,587

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Abstract: The regulations and forms cover the submission of information relating to the processing of claims for benefits under the Longshore Act and extensions.

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Authorizing Statute(s): US Code: 33 USC 901 et seq. Name of Law: Longshore and Harbor Workers' Compensation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 22806	04/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 38832	06/29/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	LS-204 , LS-200 , LS-201 , LS-513 , LS-267 , LS-203 , LS-262 , LS-274 , LS-271	Application for Self-Insurance ,   Attending Physician's Supplementary Report ,   Report of Injury Experience of Insurance Carrier or Self-Insured Employer ,   Report of Earnings ,   Notice of Employee's Injury or Death ,   Report of Payments ,   Claimant's Statement ,   Employee's Claim for Compensation ,   Claim for Death Benefits

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ICR Summary of Burden

table that charts list of burden

	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	130,036	175,374	0	0	-45,338	0
Annual Time Burden (Hours)	44,950	66,544	0	0	-21,594	0
Annual Cost Burden (Dollars)	45,979	66,587	0	0	-20,608	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden was reduced from 66,544 hours to 44,950 hours due to a decrease in reporting under the Act.

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Annual Cost to Federal Government: $252,049

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/29/2012

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