OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness

ICR 201412-1240-002 · OMB 1240-0003 · Historical Inactive

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
13653 Employer's First Report of Injury or Occupational Disease; Physician's Report on Impairment of Vision; and Employer's Supplementary Report of Accident or Occupational Illness Modified
ICR Details
1240-0003 201412-1240-002
Historical Inactive 201409-1240-004
DOL/OWCP
Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness
No material or nonsubstantive change to a currently approved collection   No
Regular
Preapproved 05/15/2015
Retrieve Notice of Action (NOA) 03/12/2015
  Inventory as of this Action Requested Previously Approved
03/31/2017 03/31/2017 03/31/2017
28,829 0 28,829
7,208 0 7,208
12,290 0 14,126
Forms LS-202 and LS-210 are used to report injuries, periods of disability, and medical treatment under the Longshore and Harbor Workers' Compensation Act.
US Code: 33 USC Chapter 18 Name of Law: Longshore and Harbor Worker's Compensation Act
  
None
Proposed rulemaking
  78 FR 57662 09/19/2013
79 FR 4977 01/30/2014
No
  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 28,829 28,829 0 0 0 0
Annual Time Burden (Hours) 7,208 7,208 0 0 0 0
Annual Cost Burden (Dollars) 12,290 14,126 0 -1,836 0 0
No
No
$19,010
No
No
No
No
No
Uncollected
Cheryl Jordan 202 693-0289 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/12/2015