Request for Examination and/or Treatment (Employee Burden)

Request for Examination and/or Treatment

OMB: 1240-0029

IC ID: 197372

Information Collection (IC) Details

View Information Collection (IC)

Request for Examination and/or Treatment (Employee Burden)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 702.419

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

Income Security General Retirement and Disability

DOL/OWCP-3  67 FR 16870

45,000 0
   
Individuals or Households
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 45,000 0 0 0 0 45,000
Annual IC Time Burden (Hours) 41,250 0 0 0 0 41,250
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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