Request for Examination and/or Treatment (Employee Burden)

Request for Examination and/or Treatment

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form LS-1 Request for Examination and/or Treatment (Employee Burden) Form
LS-1 Request for Examination and/or Treatment ls-1(1).pdf www.dol.gov/owcp/dlhwc/ls-1.pdf Form
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

IC Title:	Request for Examination and/or Treatment (Employee 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-1	Request for Examination and/or Treatment	ls-1(1).pdf	http://www.dol.gov/owcp/dlhwc/ls-1.pdf	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-3	FR Citation: 67 FR 16870

Number of Respondents: 45,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	45,000	45,000
Annual IC Time Burden (Hours)	41,250	41,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	10/01/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.