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

OMB: 1240-0003

IC ID: 13653

Information Collection (IC) Details

View Information Collection (IC)

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
 
No Modified
 
Mandatory
 
20 CFR 702.407 20 CFR 702.201 20 CFR 702.202

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-210 Employer's Supplementary Report of Accident or Occupational Illness ls-210.pdf http://www.dol.gov/owcp/dlhwc/ls-210.pdf Yes No Fillable Printable
Form and Instruction LS-202 Employer's First Report of Injury or Occupational Illness ls-202 (2).pdf http://www.dol.gov/owcp/dlhwc/ls-202.pdf Yes Yes Fillable Fileable

Income Security General Retirement and Disability

DOL/ESA-15  67 FR 16865

28,829 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   1 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 28,829 0 0 0 0 28,829
Annual IC Time Burden (Hours) 7,208 0 0 0 0 7,208
Annual IC Cost Burden (Dollars) 12,290 0 -1,836 0 0 14,126

Title Document Date Uploaded
DLHWC SEA Portal DLHWC Seaportal.pdf 09/24/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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