Request for Examination and/or Treatment

Forms and Documents

Document Name	Status
Form LS-1 Request for Examination and/or Treatment (Employee Burden) Form	Unchanged
Form LS-1 Request for Examination and/or Treatment (Employer Burden) Form	Modified
Notice to OMB Reviewer - Non Material Change for Direct Final Rule (1240-0029).docx Justification for No Material/Nonsubstantive Change	2015-03-11
Justification for non-material change.docx Justification for No Material/Nonsubstantive Change	2014-09-30
OMB - Supporting Statement for 1240-0029 (LS-1) Feb 2014.doc Supporting Statement A	2014-06-11
DOL ESA-15.pdf Supplementary Document	2011-02-17
33 USC, Chapter 18 Section 907.doc Supplementary Document	2008-01-08
20CFR702.419.pdf Supplementary Document	2008-01-08

IC Document Collections

IC ID	Document Title	Status
197372	Request for Examination and/or Treatment (Employee Burden) Form	Unchanged
13713	Request for Examination and/or Treatment (Employer Burden) Form	Modified

ICR Details

OMB Control No: 1240-0029	ICR Reference No: 201506-1240-009
Status: Historical Active	Previous ICR Reference No: 201409-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Examination and/or Treatment
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
	Date Received in OIRA: 06/05/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	08/31/2017	08/31/2017
Responses	96,000	0	96,000
Time Burden (Hours)	52,000	0	52,000
Cost Burden (Dollars)	2,085,715	0	2,088,960

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Abstract: Form LS-1 is used by employers to authorize medical treatment for injured workers and by claimants to report findings of physical examinations and treatment recommended.

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Authorizing Statute(s): US Code: 33 USC Chapter 18, Section 907 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:
	79 FR 12224	03/04/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 34364	06/16/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Request for Examination and/or Treatment (Employer Burden)	LS-1	Request for Examination and/or Treatment
Request for Examination and/or Treatment (Employee Burden)	LS-1	Request for Examination and/or Treatment

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ICR Summary 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	96,000	96,000	0	0	0	0
Annual Time Burden (Hours)	52,000	52,000	0	0	0	0
Annual Cost Burden (Dollars)	2,085,715	2,088,960	0	-3,245	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: $48,019

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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