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 201412-1240-002 · OMB 1240-0003.

⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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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 702.201 20 CFR 702.202

Information Collection Instruments:

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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 67 FR 16865

Number of Respondents: 28,829	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	Previously Approved
Annual Number of Responses for this IC	28,829	0	28,829
Annual IC Time Burden (Hours)	7,208	0	7,208
Annual IC Cost Burden (Dollars)	12,290	-1,836	14,126

Documents for IC

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