OMB control number

Report Of Injury Experience Of Self-insured Employer

OMB 1215-0033 · DOL/ESA.

OMB 1215-0033

Latest Forms, Documents, and Supporting Material

Document Name
REPORT OF INJURY EXPERIENCE OF SELF-INSURED EMPLOYER Form

All Historical Document Collections

198308-1215-001 Approved without change	Revision of a currently approved collection	1983-08-09
198206-1215-014 Approved with change	No material or nonsubstantive change to a currently approved collection	1982-06-30
197807-1215-003 Approved without change	Extension without change of a currently approved collection	1978-07-21