Request for Examination and/or Treatment

OMB 1240-0029

OMB 1240-0029

Form LS-1 is used by employers to authorize medical treatment for injured workers and by claimants to report findings of physical examinations and treatment recommended.

The latest form for Request for Examination and/or Treatment expires 2023-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material
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Supporting Statement A
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All Historical Document Collections
Approved with change
 Revision of a currently approved collection 2023-10-10
Approved without change
 Revision of a currently approved collection 2020-10-30
Approved without change
 Extension without change of a currently approved collection 2017-08-30
Approved without change
 Revision of a currently approved collection 2015-06-05
Preapproved
 No material or nonsubstantive change to a currently approved collection 2015-03-12
Approved without change
 No material or nonsubstantive change to a currently approved collection 2014-10-01
Approved without change
 Extension without change of a currently approved collection 2014-06-16
Approved without change
 Extension without change of a currently approved collection 2011-05-03
Approved without change
 Extension without change of a currently approved collection 2010-03-12
OMB Details

Request for Examination and/or Treatment (Employer Burden)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form LS-1Request for Examination and/or Treatmentwww.dol.gov/owcp/dlhwc/ls-1.pdfForm

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.

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