Supporting Statement 1240-0029 (LS-1)

Request for Examination and/or Treatment

1240-0029 (LS-1)

SUPPORTING STATEMENT

Request for Examination and/or Treatment (LS-1)

OMB No. 1240-0029

A. Justification.

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

The Office of Workers' Compensation Programs (OWCP) administers the Longshore and Harbor Workers' Compensation Act (LHWCA). The Act provides benefits to workers injured in maritime employment on the navigable waters of the United States or in an adjoining area customarily used by an employee in loading, unloading, repairing or building a vessel. In addition, several acts extend coverage to certain other employees. LSHWCA section 39(a) generally authorizes the Secretary of Labor to prescribe rules and regulations to implement the Act. See 33 U.S.C. § 939(a).

Under section 7 (33 USC, Chapter 18, Section 907) of the Longshore Act and 20 C.F.R. 702.419, the employer/insurance carrier is responsible for furnishing medical care for the injured employee for such period of time as the injury or recovery period may require. Form LS-1 serves two purposes: it authorizes the medical care, and it provides a vehicle for the treating physician to report the findings, treatment given, and anticipated physical condition of the employee.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The information collected on Form LS-1 is used by the Longshore Division to verify that proper medical treatment has been authorized by the employer/insurance carrier, and to determine the severity of a claimant's injuries and thus his/her entitlement to compensation benefits. The employers/insurance carriers are responsible by law to provide these benefits if a claimant is medically unable to work as a result of a work-related injury. If the information were not collected, verification of authorized medical care and entitlement to compensation benefits would not be possible.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Respondents now have the option of completing and submitting the form LS-1 electronically using our new secure web portal (https://seaportal.dol-esa.gov). The form itself is located on our website at http://www.dol.gov/owcp/dlhwc/ls-1.pdf.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

This form has been carefully reviewed to eliminate requests or duplicate information. The LS-1 is a unique form in that it is used by three separate parties. Part A is for the employer/insurance carrier to authorize treatment by the physician selected by the injured worker. The employee must then take the form to the selected physician for treatment. Part B is used by the treating physician to report on the medical diagnosis and prognosis of the injured worker.

5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.

The information is not requested from small businesses or other small entities and does not have a significant economic impact on a substantial number of small entities.

6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

The form is used only for the initial authorization and examination and therefore cannot be used less frequently.

7. Explain any special circumstances.

* Requiring respondents to report information to the agency more often than quarterly;

* Requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

* Requiring respondents to submit more than an original and two copies of any document;

* Requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

* In connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

* Requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

* That includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

* Requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

Since the form is completed only at the time an injury occurs, it is completed on occasion rather than quarterly. In accordance with section 907(e) of the law, the form is to be submitted within 10 days following the first treatment. Other than these circumstances, there are no other special circumstances for the collection of this information.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.

Specifically address comments received on cost and hour burden. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years—even if the collection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

Consultations were held with industry representatives individually and at seminars at the time the Act was amended in 1972. The form was developed as a result of these consultations. The format of the form is basic in that the first part merely authorizes medical treatment by a physician selected by the injured worker, and the second part provides space for the physician to report the findings of the medical treatment provided. Daily contact maintained with representatives of insurance carriers and self-insurers by OWCP district office personnel with whom the form is filed has not revealed any undue burden. If any complaints or suggestions for improvement are received, they are forwarded to the National Office for review and appropriate action.

A Federal Register Notice inviting public comment on this collection of information was published in the Federal Register on 6/11/2020 (85 FR 35669). No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts are provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

While no assurance of confidentiality is provided to respondents, to the extent records pertaining to specific compensation cases are disclosed, they are protected under the Privacy Act. Otherwise, the information collected is not protected under the Privacy Act. The Privacy Act Systems of Records is entitled DOL/OWCP-3.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

Form LS-1 collects information related to an employee’s health condition. The information is limited to that necessary to determine the employee’s entitlement to benefits under the Longshore Act and related Act that extend similar benefits to other workers.

12. Provide estimates of the hour burden of the collection of information. The statement should:

* Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

* If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens.

* Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included under “Annual Cost to Federal Government.”

Burden has been estimated to be approximately 48,750 hours (see table below). It is estimated that approximately 45,000 Forms LS-1 are used each year. Approximately 15,000 employers will complete approximately 3 forms each and 45,000 employees will each be responsible for having their health care professional complete Part B of the form. The number of forms that each respondent will complete is an estimate since some may complete more than 3 forms and some less. The time needed for an employer to complete each form has been estimated to be approximately 5 minutes for each side for a total of 10 minutes. The time estimated for an employee to travel to the physician, undergo the physical examination and have the physician complete the form is 55 minutes. This estimate is considered reasonable since some examinations for very minor injuries such as minor cuts, burns and bruises will take less time while examinations for more serious injuries will take longer. Also, since the injured employee is permitted to choose his/her own physician, the physician will generally be located close to the employee's home. This estimate is an average since some trips may take less and others more time depending on the distance to the physician's office.

The annualized burden cost to the respondents is estimated to be approximately $950,625. This estimate was derived from the National Average Weekly Wage (NAWW) as computed by the Bureau of Labor Statistics based on the national average earnings of production and non-supervisory workers on private non-agricultural payrolls. Section 6(b) of the Longshore and Harbor Workers’ Compensation Act mandates the use of the NAWW in setting the maximum and minimum compensation rates and in determining the amount of annual adjustments due to permanent total disability and death. Since it is not possible to determine the specific occupation or wages for each person who will provide the information covered by this clearance, and wages can vary considerably from person to person depending on locale as well as duties and length of service, use of a national average weekly wage covering all occupations appears reasonable under the circumstances. The current applicable NAWW is $780.04. The computations are therefore as follows:

$780.04 ÷ 40 = $19.50/hr.

$19.50 x 48,750 hours = $950,625 annualized burden cost.

Burden Summary Table

Activity	Number of Respondents	Annual Frequency	Total Annual Responses	Time Per Response	Total Annual Burden (Hours)	Hourly Rate*	Monetized Value of Respondent Time
Employer Burden	15,000	3	45,000	10 minutes	7,500	$19.50	$146,250
Employee Burden	45,000	1	45,000	55 minutes	41,250	$19.50	$804,375
Unduplicated Totals	60,000	NA	90,000	NA	48,750	$19.50	$950,625

13. Provide an estimate for the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden already reflected on the burden worksheet).

* The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life) and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

* If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collections services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

* Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

This information collection does not require the use of systems or technology for generating, maintaining or disclosing the data above that which would already be kept as a customary business practice. The cost of an exam by the physician is approximately $225.00. It is estimated that the physician takes approximately 15 minutes to perform the exam and another 15 minutes to complete the form. Total cost of the physician’s time is approximately $56.25 ($225.00 x .25 minutes to complete form) per form for a total of $2,531,250 for the 45,000 forms. This represents a pro rata share of the medical exam as it relates to the time needed to gather information for the completion of this form.

Since respondents now have the option to submit the forms electronically, the number of forms sent through the mail has decreased thus allowing a significant reduction in cost. The decrease in cost is estimated to be 50%. A mailing cost of $.58 per response ($.55 postage and $.03 envelope charge) is applied as an operation cost for a total of $13,050 for the 45,000 responses ($.58 x 45,000 forms = $26,100 – 50% = $13,050). Total cost for physician’s time plus mailing cost is $2,544,300.

14. Provide estimates of annualized cost to the Federal government. Provide estimates of annualized costs to the Federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies may also aggregate cost estimates from Items 12, 13, and 14 in a single table.

The cost to the government is estimated to be approximately $110,586.00. This estimate was determined by taking into consideration analysis costs associated with the review of Form LS-1. Analysis and handling costs were determined by applying the hourly rate of a GS-13, step 5 claims examiner FY20 Salary Table – Rest of US) https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2020/RUS_h.pdf ($49.54) to the total annual hours required for review. The annual review hours were determined by applying an estimate of .02 hours or 1 minute for the review and analysis of each of the 45,000 forms, received each year. The annual cost to maintain the entire SEAPortal website is $66,000.00.The calculations are as follows:

45,000 x .02 = 900 x $39.19 = $44,586.00 + $66,000.00 = $110,586.00

15. Explain the reasons for any program changes or adjustments.

The number of responses has remained unchanged (90,000) since the last clearance submission. Burden hours have also remained unchanged (48,750). There has been an increase in the operation and maintenance costs from $1,484,816 to $2,544,300 due to the increase in the cost of a physician’s exam.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

The information collected will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

OWCP previously sought approval not to display the expiration

date. The agency is not making that request for this clearance and

will now display the date.

18. Explain each exception to the certification statement in ROCIS.

There are no exceptions to the certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.