Information Collection

Request for Examination and/or Treatment (Employer Burden)

IC 13713 under ICR 201102-1240-002 · OMB 1240-0029.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0029 can be found here:

Documents and Forms

Document Name Document Type
Form LS-1 Request for Examination and/or Treatment (Employer Burden) Form
LS-1 Request for Examination and/or Treatment ls-1.pdf www.dol.gov/owcp/dlhwc/ls-1.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Examination and/or Treatment (Employer Burden)	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 702.419

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-1	Request for Examination and/or Treatment	ls-1.pdf	http://www.dol.gov/owcp/dlhwc/ls-1.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/GOVT-15	FR Citation: 67 FR 16870

Number of Respondents: 24,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	72,000	-3,000	75,000
Annual IC Time Burden (Hours)	12,000	-69,000	81,000
Annual IC Cost Burden (Dollars)	3,417,840	-140,160	3,558,000

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.