Information Collection

Request for Examination and/or Treatment (Employer Burden)

IC 13713 under ICR 202309-1240-003 · OMB 1240-0029.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-1 Request for Examination and/or Treatment (Employer Burden)	Form
LS-1 Request for Examination and/or Treatment ls-1.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-1.pdf	Form
LS-1 Request for Examination and/or Treatment ls-1.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-1.pdf	Form
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document

IC Title:

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:

table that charts list of 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.pdf	https://www.dol.gov/sites/dolgov/files/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: 36,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	36,000	-9,000	45,000
Annual IC Time Burden (Hours)	6,000	-1,500	7,500
Annual IC Cost Burden (Dollars)	2,700,000	155,700	2,544,300

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

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