Information Collection

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act

IC 43808 under ICR 201003-1240-014 · OMB 1240-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0014 can be found here:

Documents and Forms

Document Name Document Type
Form LS-201 proposed Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form
ESA 100.doc Other-Recordkeeping
LS-201 proposed Notice of Employee's Injury or Death LS-201 proposed.pdf www.dol.gov/esa/owcp/dlhwc/ls-201.pdf Form
LS-513 proposed Report of Payments LS-513 proposed.pdf Form
LS-267 proposed Claimant's Statement LS-267 proposed.pdf www.dol.gov/esa/owcp/dlhwc/LS-267.pdf Form
LS-203 proposed Employee's Claim for Compensation LS-203 proposed.pdf www.dol.gov/esa/owcp/dlhwc/ls-203.pdf Form
LS-262 proposed Claim for Death Benefits LS-262 proposed.pdf www.dol.gov/esa/owcp/dlhwc/ls-262.pdf Form
LS-271 proposed Application for Self-Insurance LS-271 proposed.pdf www.dol.gov/esa/owcp/dlhwc/LS-271.pdf Form
LS-204 proposed Attending Physician's Supplementary Report ls-204 proposed.pdf www.dol.gov/esa/owcp/dlhwc/ls-204.pdf Form
LS-274 proposed Report of Injury Experience of Insurance Carrier or Self ls-274 proposed.pdf www.dol.gov/esa/owcp/dlhwc/LS-274.pdf Form
LS-200 proposed Report of Earnings ls-200 proposed.pdf www.dol.gov/esa/owcp/dlhwc/ls-200.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	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 703.310 20 CFR 702.162 20 CFR 702.175 20 CFR 702.174 20 CFR 702.321 20 CFR 702.242 20 CFR 702.285 20 CFR 702.202 20 CFR 702.221 20 CFR 702.201 20 CFR 702.111

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-204 proposed	Attending Physician's Supplementary Report	ls-204 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-204.pdf	Yes	No	Fillable Printable
Form	LS-200 proposed	Report of Earnings	ls-200 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-200.pdf	Yes	No	Fillable Printable
Other-Recordkeeping			ESA 100.doc		No		Paper Only
Form	LS-201 proposed	Notice of Employee's Injury or Death	LS-201 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-201.pdf	Yes	No	Fillable Printable
Form	LS-513 proposed	Report of Payments	LS-513 proposed.pdf		No		Paper Only
Form	LS-267 proposed	Claimant's Statement	LS-267 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/LS-267.pdf	Yes	No	Printable Only
Form	LS-203 proposed	Employee's Claim for Compensation	LS-203 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-203.pdf	Yes	No	Fillable Printable
Form	LS-262 proposed	Claim for Death Benefits	LS-262 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-262.pdf	Yes	No	Fillable Printable
Form	LS-274 proposed	Report of Injury Experience of Insurance Carrier or Self-Insured Employer	ls-274 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/LS-274.pdf	Yes	No	Fillable Printable
Form	LS-271 proposed	Application for Self-Insurance	LS-271 proposed.pdf	http://www.dol.gov/esa/owcp/dlhwc/LS-271.pdf	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 58 FR 49599

Number of Respondents: 175,374	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	175,374	-6,694	182,068
Annual IC Time Burden (Hours)	66,544	-4,832	71,376
Annual IC Cost Burden (Dollars)	66,587	1,587	65,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.