Request for Examination and/or Treatment

Forms and Documents

Document Name	Status
Form LS-1 Request for Examination and/or Treatment (Employee Burden) Form	Modified
Form LS-1 Request for Examination and/or Treatment (Employer Burden) Form	Modified
Supporting Statement 1240-0029 (LS-1).docx Supporting Statement A	2020-10-30
30-day FRN (1240-0029) published.pdf Supplementary Document	2020-10-30
60-day FRN (1240-0029) published.pdf Supplementary Document	2020-10-30
DOL OWCP-3.docx Supplementary Document	2020-06-05
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	Modified
13713	Request for Examination and/or Treatment (Employer Burden) Form	Modified

ICR Details

OMB Control No: 1240-0029	ICR Reference No: 202006-1240-001
Status: Active	Previous ICR Reference No: 201702-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Examination and/or Treatment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/29/2020
	Date Received in OIRA: 10/30/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved	12/31/2020
Responses	90,000	0	90,000
Time Burden (Hours)	48,750	0	48,750
Cost Burden (Dollars)	2,544,300	0	1,484,816

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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 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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 35669	06/11/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 68599	10/29/2020
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	90,000	90,000	0	0	0	0
Annual Time Burden (Hours)	48,750	48,750	0	0	0	0
Annual Cost Burden (Dollars)	2,544,300	1,484,816	0	0	1,059,484	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: $110,586

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: 10/30/2020

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