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

ICR 201506-1240-006

OMB: 1240-0003

Federal Form Document

ICR Details
1240-0003 201506-1240-006
Historical Active 201409-1240-004
DOL/OWCP
Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/05/2015
Retrieve Notice of Action (NOA) 06/05/2015
  Inventory as of this Action Requested Previously Approved
03/31/2017 03/31/2017 03/31/2017
28,829 0 28,829
7,208 0 7,208
12,290 0 14,126

Forms LS-202 and LS-210 are used to report injuries, periods of disability, and medical treatment under the Longshore and Harbor Workers' Compensation Act.

US Code: 33 USC Chapter 18 Name of Law: Longshore and Harbor Worker's Compensation Act
  
None

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

  78 FR 57662 09/19/2013
79 FR 4977 01/30/2014
No

  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 28,829 28,829 0 0 0 0
Annual Time Burden (Hours) 7,208 7,208 0 0 0 0
Annual Cost Burden (Dollars) 12,290 14,126 0 -1,836 0 0
No
No

$19,010
No
No
No
No
No
Uncollected
Cheryl Jordan 202 693-0289 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/12/2015


© 2024 OMB.report | Privacy Policy