Information Collection

Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness

IC 13653 under ICR 202312-1240-001 · OMB 1240-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0003 can be found here:

Documents and Forms

Document Name Document Type
Form LS-210 Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness Form
LS-210 Employer's Supplementary Report of Accident or Occupatio ls-210 (002).pdf www.dol.gov/owcp/dlhwc/ls-210.pdf Form
LS-210 Employer's Supplementary Report of Accident or Occupatio ls-210 (002).pdf www.dol.gov/owcp/dlhwc/ls-210.pdf Form
LS-202 Employer's First Report of Injury or Occupational Illnes ls-202.pdf www.dol.gov/owcp/dlhwc/ls-202.pdf Form and Instruction
LS-202 Employer's First Report of Injury or Occupational Illnes ls-202.pdf www.dol.gov/owcp/dlhwc/ls-202.pdf Form and Instruction
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	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 702.202 20 CFR 702.407 20 CFR 702.201

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-210	Employer's Supplementary Report of Accident or Occupational Illness	ls-210 (002).pdf	http://www.dol.gov/owcp/dlhwc/ls-210.pdf	Yes	No	Fillable Printable
Form and Instruction	LS-202	Employer's First Report of Injury or Occupational Illness	ls-202.pdf	http://www.dol.gov/owcp/dlhwc/ls-202.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: 58 FR 49599

Number of Respondents: 43,039	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	43,039	18,408	24,631
Annual IC Time Burden (Hours)	10,760	4,602	6,158
Annual IC Cost Burden (Dollars)	611	-6,532	7,143

Documents for IC

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.