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

Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness

⚠️ Notice: This information collection may be referencing outdated material.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

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

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

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.