Request for Intervention, Longshore and Harbor Workers' Compensation Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form LS-6 LS-6 Commutation Application	Form and Instruction	New	Available
Form LS-9 Stipulation Approval Request	Form and Instruction	New	Available
Form LS-8 Settlement Approval Request Section 8(i)	Form and Instruction	New	Available
Form LS-7 Request for Intervention	Form and Instruction	New	Available
Form LS-5 Aplication for Special Fund Relief	Form and Instruction	New	Available
Form LS-4 Attorney Fee Approval Request	Form and Instruction	New	Available
1240-0NEW Supporting Statement (112519).docx	Supporting Statement A	Uploaded 2019-11-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237986	Request for Intervention, Longshore and Harbor Workers' Compensation Act	Form and Instruction	New	LS-6 Commutation Application
237986	Request for Intervention, Longshore and Harbor Workers' Compensation Act	Form and Instruction	New	Stipulation Approval Request
237986	Request for Intervention, Longshore and Harbor Workers' Compensation Act	Form and Instruction	New	Settlement Approval Request Section 8(i)
237986	Request for Intervention, Longshore and Harbor Workers' Compensation Act	Form and Instruction	New	Request for Intervention
237986	Request for Intervention, Longshore and Harbor Workers' Compensation Act	Form and Instruction	New	Aplication for Special Fund Relief
237986	Request for Intervention, Longshore and Harbor Workers' Compensation Act	Form and Instruction	New	Attorney Fee Approval Request

ICR Details

OMB Control No: 1240-0058	ICR Reference No: 201910-1240-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Intervention, Longshore and Harbor Workers' Compensation Act
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/03/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/25/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved
Responses	12,414	0	0
Time Burden (Hours)	3,191	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Parties to LHWCA claims ask OWCP District Directors, who administer claims, to take a variety of routine actions, each depending on the claim. Currently, there is no uniform method for either requesting DD action or submitting the information necessary for the DD to evaluate the request. Parties submit the information in various formats. Capturing the required information in one form will save time, effort and cost for the federal government and simplify filing for the parties. The forms will also help OWCP properly classify different types of documents as it moves into a fully electronic case file environment and speed delivery of services to stakeholders.

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Authorizing Statute(s): US Code: 33 USC 939 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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 38672	08/07/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 64106	11/20/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for Intervention, Longshore and Harbor Workers' Compensation Act	LS-5, LS-8, LS-4, LS-6, LS-9, LS-7	Attorney Fee Approval Request ,   Aplication for Special Fund Relief ,   Request for Intervention ,   Settlement Approval Request Section 8(i) ,   Stipulation Approval Request ,   LS-6 Commutation Application

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ICR Summary of Burden

table that charts list 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	12,414	0	0	12,414	0	0
Annual Time Burden (Hours)	3,191	0	0	3,191	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden has been estimated by multiplying the estimated average response time with the estimated responses. The estimated responses were determined by a review of OWCP data maintained by the National Office, which reflect the number of requests made in FY2018, and the number of requests filed electronically. The response time is based on experience with the usual requests. The estimate takes into consideration that some cases require more information than others due to the complexity of the issues involved and the minute estimate should therefore be considered as an average time needed to gather the information, complete the form, obtain required signatures, and submit the required information.

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Annual Cost to Federal Government: $8,496

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 11/25/2019

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