Information Collection

Request for Examination and/or Treatment (Employer Burden)

IC 13713 under ICR 201702-1240-001 · OMB 1240-0029.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0029 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-1 Request for Examination and/or Treatment Request for Examination and/or Treatment (Employer Burden)	Form
LS-1 Request for Examination and/or Treatment Proposed LS-1.pdf www.dol.gov/owcp/dlhwc/ls-1.pdf	Form
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document

IC Title:

Request for Examination and/or Treatment (Employer Burden)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.419

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-1			http://www.dol.gov/owcp/dlhwc/ls-1.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/GOVT-15

FR Citation: 67 FR 16870

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 13 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	45,000	-3,000	48,000
Annual IC Time Burden (Hours)	7,500	-500	8,000
Annual IC Cost Burden (Dollars)	1,484,816	-600,899	2,085,715

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DLHWC SEA Portal		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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