OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Request for Examination and/or Treatment

OMB 1240-0029 ยท DOL/OWCP.

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 2026-11-30 and is listed under ICR 202309-1240-003.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form LS-1 Request for Examination and/or Treatment (Employee Burden)Form
Form LS-1 Request for Examination and/or Treatment (Employer Burden)Form
2023 30-Day FRN_1240-0029.pdf Supplementary Document
2023 60-Day FRN_1240-0029.pdf Supplementary Document
Supporting Statement for 1240-0029 September 2023_CLEAN.docxSupporting Statement A
DOL OWCP-3.docx Supplementary Document
33 USC, Chapter 18 Section 907.doc Supplementary Document
20CFR702.419.pdf Supplementary Document
Request for Examination and/or Treatment (Employee Burden) Form
Request for Examination and/or Treatment (Employer Burden) Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202309-1240-003 Revision of a currently approved collection 2023-10-10 Approved with change
202006-1240-001 Revision of a currently approved collection 2020-10-30 Approved without change
201702-1240-001 Extension without change of a currently approved collection 2017-08-30 Approved without change
201506-1240-009 Revision of a currently approved collection 2015-06-05 Approved without change
201412-1240-009 No material or nonsubstantive change to a currently approved collection 2015-03-12 Preapproved
201409-1240-002 No material or nonsubstantive change to a currently approved collection 2014-10-01 Approved without change
201403-1240-001 Extension without change of a currently approved collection 2014-06-16 Approved without change
201102-1240-002 Extension without change of a currently approved collection 2011-05-03 Approved without change
201003-1240-029 Extension without change of a currently approved collection 2010-03-12 Approved without change

OMB Details

Request for Examination and/or Treatment (Employer Burden)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Information collection instruments
FormNameElectronic accessType
Form LS-1Request for Examination and/or Treatmentwww.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-1.pdfForm

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