Information Collection

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

IC 13653 under ICR 201611-1240-004 · OMB 1240-0003.

⚠️ Notice: This information collection may be referencing outdated material.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
Form LS-210 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 Form
LS-210 Employer's Supplementary Report of Accident or Occupatio ls-210 2017.pdf www.dol.gov/owcp/dlhwc/ls-210.pdf Form
LS-202 Employer's First Report of Injury or Occupational Illnes ls-202 2017.pdf www.dol.gov/owcp/dlhwc/ls-202.pdf Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

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 702.202 20 CFR 702.201

Information Collection Instruments:

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 2017.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 2017.pdf	http://www.dol.gov/owcp/dlhwc/ls-202.pdf	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 58 FR 49599

Number of Respondents: 24,631	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24,631	-4,198	28,829
Annual IC Time Burden (Hours)	6,158	-1,050	7,208
Annual IC Cost Burden (Dollars)	11,143	-1,147	12,290

Documents for IC

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.