Information Collection

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

IC 13653 under ICR 202403-1240-002 · OMB 1240-0003.

Documents and Forms

Documents and forms in this information collection
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
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 3-19-24.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-202.pdf	Form and Instruction
LS-202 Employer's First Report of Injury or Occupational Illnes ls-202 3-19-24.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-202.pdf	Form and Instruction
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 702.202 20 CFR 702.407 20 CFR 702.201

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-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 3-19-24.pdf	https://www.dol.gov/sites/dolgov/files/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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	43,039	43,039
Annual IC Time Burden (Hours)	10,760	10,760
Annual IC Cost Burden (Dollars)	611	611

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.