Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form LS-202 Employer's First Report of Injury or Occupational Illness	Form and Instruction	Modified	Repair queued
Form LS-210 Employer's Supplementary Report of Accident or Occupational Illness	Form	Modified	Available
Form LS-202 Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	Form and Instruction	Modified	Repair queued
1240-0003 Form Updates.docx	Supplementary Document	Uploaded 2020-06-25	Repair queued
OMB - Supporting Statement for 1240-0003 June 2020.docx	Supporting Statement A	Uploaded 2020-06-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13653	Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	Form and Instruction	Modified	Employer's First Report of Injury or Occupational Illness
13653	Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	Form	Modified	Employer's Supplementary Report of Accident or Occupational Illness
13653	Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0003	ICR Reference No: 202002-1240-002
Status: Historical Active	Previous ICR Reference No: 201611-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/11/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/25/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2024	36 Months From Approved	02/28/2021
Responses	24,631	0	24,631
Time Burden (Hours)	6,158	0	6,158
Cost Burden (Dollars)	7,143	0	11,143

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Abstract: Forms LS-202 and LS-210 are used to report injuries, periods of disability, and medical treatment under the Longshore and Harbor Workers' Compensation Act.

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Authorizing Statute(s): US Code: 33 USC 930 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:
	85 FR 19777	04/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 37691	06/23/2020
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
Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	LS-210, LS-202	Employer's Supplementary Report of Accident or Occupational Illness ,   Employer's First Report of Injury or Occupational Illness

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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	24,631	24,631	0	0	0	0
Annual Time Burden (Hours)	6,158	6,158	0	0	0	0
Annual Cost Burden (Dollars)	7,143	11,143	0	-4,000	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: $90,404

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? No

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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: 06/25/2020

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