Supporting Statement for 1240-0029 September 2023_CLEAN

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

OMB Control Number: 1240-0029

OMB Expiration Date: December 31, 2023

SUPPORTING STATEMENT FOR

REQUEST FOR EXAMINATION AND/OR TREATMENT (LS-1)

OMB CONTROL NO. 1240-0029

This ICR seeks to revise a currently approved collection.

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). LHWCA 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 employer in loading, unloading, repairing, or building a vessel. In addition, several Acts extend the Longshore Act's coverage to certain other employees.

The Secretary of Labor has authority to make rules and regulations to establish procedures which are necessary or appropriate to carry out the provisions of the Act. 33 U.S.C. §§ 939, 944. The Secretary has delegated that authority to the Director, Office of Workers’ Compensation Programs. Secretary’s Order 10–2009; Pub. L. 111–5 § 803, 123 Stat. 115, 187 (2009).

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 Program to verify that medical treatment has been authorized by the employer/insurance carrier in compliance with the Act, and to determine the severity of a claimant's injuries and thus their 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.gov). The form itself is located on our website at https://www.dol.gov/sites/dolgov/files/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 the medical diagnosis and prognosis of the injured worker.

5. If the collection of 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 to 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.

A notice inviting public comment was published in the Federal Register on 07/07/2023. Comments were not received. 

In addition, OWCP and Longshore leadership invite comment and feedback on processes and forms on a continual basis with regularly scheduled meetings with stakeholders including, but not limited to: four to five conferences per year during which OWCP is a presenter to keep our stakeholders apprised and field their questions, comments and concerns; annual Carrier Performance Meetings with OWCP leadership and the largest carriers; special requests for in person and/or virtual meetings with stakeholders throughout the year; outreach efforts at the District Office and National Office levels; and continual communication with all stakeholders.

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.

Where records pertain to specific compensation cases, the completed forms will be maintained in the claimant’s case file. Thus, the information collected is covered by Privacy Act Systems of Records, DOL/OWCP-3, published at 81 Federal Register 25765 (April 29, 2016), or as updated and republished. Otherwise, the information collected is not protected under the Privacy Act.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered 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 its extensions.

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 reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.¹

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• 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 in Item 14.

The burden for this collection is an estimated 128.62 hours (see table below). In FY2022, 118 Forms LS-1 were received (part A filled out by Employer/Insurance Carrier and Part B filled out by Employee/Treating Physician). The time needed for an employer to complete each form is approximately 5 minutes per 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 their own physician, the physician will generally be located close to the employee's home. This estimate is an average since some trips may take more or less time depending on the distance to the physician's office.

The annualized burden cost for respondents time is approximately $2,947.98.

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The annualized burden cost estimates are calculated using the National Average Weekly Wage (NAWW), as computed by the Bureau of Labor Statistics, https://www.dol.gov/agencies/owcp/dlhwc/NAWWinfo, for production or non-supervisory workers on private non-agriculture payrolls in a 40 hour work week. Section 6(b) of the Act mandates the use of the NAWW in setting the maximum and minimum compensation rates under the Act and in determining the amount of annual adjustments for permanent total disability and for death benefits. See 33 U.S.C. 906(b). 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 duties and length of service, use of a national average weekly wage covering all occupations is reasonable. The FY2023 applicable NAWW is $916.99. The average work week is 40 hours. The Annualized Burden Cost was computed using the NAWW divided by 40 hours per week multiplied by the Burden Hours. The computations are therefore as follows:

BURDEN SUMMARY

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours) (Rounded)	Total Burden (Hours)	Hourly Wage Rate	Total Burden Cost (Rounded)
LS-1 Employee Burden	118	1	118	.92	108.56	$22.92	$2,488.20
LS-1 Employer Burden	118	1	118	.17	20.06	$22.92	$459.78
Total	236		236		128.62		$2,947.98

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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

There are no start-up costs associated with this collection. All forms may be submitted electronically at no cost.

This information collection does not require the use of systems or technology for generating, maintaining or disclosing the above data which would be kept as a customary business practice. The cost of an exam by the physician is approximately $300.00. 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 $75.00 ($300.00 x .25 hours to complete form) per form for a total of $8,850.00 for the 118 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.

14. 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.

Estimates of annualized cost to the Federal Government for all of the forms and regulations associated with this clearance are as follows:

The forms are now available online so there are no longer printing and distribution costs associated with them. The estimates now only include the costs of analysis of the completed forms once received.

The cost to the government is estimated to be approximately $6,706.15. 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-12/Step 5 workers’ compensation claims examiner taken from the 2023 Rest of the U.S. pay chart to the 1.2 minutes (0.2 hour) it takes to review each form. The cost is figured as follows:

5 Form	Grade/Rate	Analysis (Hours)	# of Forms	Federal Cost
LS-1	GS-12s5/$44.98	.02	118	$106.15
Total	--	--	--	$106.15

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Total cost to the government for all forms is $6,706.15 ($106.15 + ($66,000/10)* = $106.15 + $6,600 = $6,706.15

*The cost to maintain SEAPortal is $66,000 so this has been divided over the total Information Collection Requests (ICRs) that are impacted.

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

The number of respondents decreased from 90,000 to 236 due to the decrease in the number of forms submitted.² The Longshore Program ran a query for FY22 on how many LS-1 forms were received and that number was 118.

The annualized burden cost for mailing is reduced to zero (reduced by $13,050) as the submissions may be made electronically via the SEAPortal.

The cost to the government has been reduced by $44,479.85 due to decrease in amount of LS-1 forms received and review done by GS-12 claims examiners, not GS-13 claims specialists.

The annualized burden hours and cost decreased by 48,621.38 hours and $947,677.02 due to the decreased use of the form LS-1 and increase in electronic submissions that do not require postage or envelope costs.

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 for statistical use.

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.

The expiration date will be displayed on the forms.

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.

1 The LHWCA retention period for claims is 15 years as noted in the record schedule DAA-0271-2017-0005.

2 Stakeholders have the option to use this form or submit medical reports. The reduction in usage is likely due to the fact that stakeholders mostly choose to submit medical reports.

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