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
Form LS-200 Report of Earnings	Form	Modified	Available
Form LS-274 Report of Injury Experience of Insurance Carrier or Self-Insured Employer	Form	Modified	Available
Form LS-204 Attending Physician's Supplementary Report	Form	Modified	Available
Form LS-271 Application for Self-Insurance	Form	Modified	Available
Form LS-262 Claim for Death Benefits	Form	Modified	Available
Form LS-203 Employee's Claim for Compensation	Form	Modified	Repair queued
Form LS-267 Claimant's Statement	Form	Modified	Available
Form LS-513 Report of Payments	Form	Modified	Repair queued
Form LS-201 Notice of Employee's Injury or Death	Form	Modified	Available
Notice to OMB Reviewer - Non Material Change for Direct Final Rule (1240-0014).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-12-23	Available
Justification for non-material change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-09-30	Repair queued
OMB - Supporting Statement for 1240-0014 - 513 changes 11-19-13.docx	Supporting Statement A	Uploaded 2014-07-03	Available
NOTE TO REVIEWER-OMB.doc.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-07-03	Available
WORKSHEET FOR OMB NO 1240-0014 Nov 2013.docx	Supplementary Document	Uploaded 2013-12-20	Available

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	Form	Modified	Report of Earnings
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Report of Injury Experience of Insurance Carrier or Self-Insured Employer
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Attending Physician's Supplementary Report
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Application for Self-Insurance
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Claim for Death Benefits
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Employee's Claim for Compensation
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Claimant's Statement
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Report of Payments
43808	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Form	Modified	Notice of Employee's Injury or Death
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: 201506-1240-005
Status: Historical Active	Previous ICR Reference No: 201409-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/05/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/05/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	01/31/2017	01/31/2017
Responses	130,036	0	130,036
Time Burden (Hours)	44,955	0	44,955
Cost Burden (Dollars)	41,257	0	46,866

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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:
	Final or interim final rulemaking	80 FR 12917	03/12/2015

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 57416	09/18/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 78389	12/26/2013
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-274 , LS-267 , LS-203 , LS-262 , LS-271	Notice of Employee's Injury or Death ,   Report of Payments ,   Claimant's Statement ,   Employee's Claim for Compensation ,   Claim for Death Benefits ,   Application for Self-Insurance ,   Attending Physician's Supplementary Report ,   Report of Injury Experience of Insurance Carrier or Self-Insured Employer ,   Report of Earnings

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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	130,036	0	0	0	0
Annual Time Burden (Hours)	44,955	44,955	0	0	0	0
Annual Cost Burden (Dollars)	41,257	46,866	0	-5,609	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:

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Annual Cost to Federal Government: $252,544

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: 03/12/2015

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