Notice of Controversion of Right to Compensation

Forms and Documents

Document Name	Status
Form LS-207 Notice of Controversion of Right to Compensation Form	Modified
Justification for non-material change.docx Justification for No Material/Nonsubstantive Change	2014-09-30
OMB - Supporting Statement for 1240-0042 (LS-207) March 2015.doc Supporting Statement A	2015-03-30
5 USC 914(d).doc Supplementary Document	2008-10-20
20 CFR 702.251.doc Supplementary Document	2008-06-19

IC Document Collections

IC ID	Document Title	Status
13638	Notice of Controversion of Right to Compensation Form	Modified

ICR Details

OMB Control No: 1240-0042	ICR Reference No: 201411-1240-001
Status: Historical Active	Previous ICR Reference No: 201409-1240-008
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Controversion of Right to Compensation
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: 05/20/2015
	Date Received in OIRA: 02/27/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	05/31/2015
Responses	18,000	0	17,500
Time Burden (Hours)	4,500	0	4,375
Cost Burden (Dollars)	8,112	0	9,013

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Abstract: The LS-207 is used by insurance carriers and self-insured employers to controvert claims under the Longshore Act and extensions.

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Authorizing Statute(s): US Code: 33 USC 914(d) Name of Law: Longshore and Harbor Worker's 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:
	79 FR 71130	12/01/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 10718	02/27/2015
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Notice of Controversion of Right to Compensation	LS-207	Notice of Controversion of Right to Compensation

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ICR Summary 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	18,000	17,500	0	0	500	0
Annual Time Burden (Hours)	4,500	4,375	0	0	125	0
Annual Cost Burden (Dollars)	8,112	9,013	0	-901	0	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: The burden hours for this information collection have increased from the previous submission of 4,375 to 4,500, which is an adjustment of +125, which is due to an increase in the actual number of forms received this year. There has been a net decrease in the operation and maintenance cost from the previous submission of $9,012.50 to $8,112.00 which is a difference of -$900.50. This change is due a combination of the increase in the cost of postage and the decrease in cost associated with printing paper copies of the LS-207 form. The form is now available on the Internet (http://www.dol.gov/owcp/dlhwc/ls-207.pdf) and respondents have the ability to file the form electronically via the Secure Electronic Access Portal (SEAPortal). For this reason, the Department is no longer claiming burden costs associated with printing paper copies of the LS-207 form. The DOL has made cosmetic changes to Form LS-207, such as expanding the size of boxes used for responding, updating the instructions, and addition of instructions for injured workers and beneficiaries. These changes are not expected to change the public burden.

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Annual Cost to Federal Government: $54,346

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: 02/27/2015

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