Request for Examination and/or Treatment (Employer Burden)

Request for Examination and/or Treatment

OMB: 1240-0029

IC ID: 13713

Documents and Forms

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
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document