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

ICR 202002-1240-002 · OMB 1240-0003 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0003 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form LS-202 Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	Form and Instruction	Modified	Repair queued
1240-0003 Form Updates.docx	Supplementary Document	Uploaded 2020-06-25	Repair queued
OMB - Supporting Statement for 1240-0003 June 2020.docx	Supporting Statement A	Uploaded 2020-06-25	Missing upstream

IC Document Collections

IC ID	Collection	Type	Status	Form
13653	Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0003	ICR Reference No: 202002-1240-002
Status: Received in OIRA	Previous ICR Reference No: 201611-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 06/25/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	24,631	24,631
Time Burden (Hours)	6,158	6,158
Cost Burden (Dollars)	7,143	11,143

Abstract: 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.

Authorizing Statute(s): US Code: 33 USC 930 Name of Law: Longshore and Harbor Workers' Compensation Act

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 19777	04/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 37691	06/23/2020
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness	LS-202, LS-210	Employer's First Report of Injury or Occupational Illness , Employer's Supplementary Report of Accident or Occupational Illness

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	24,631	24,631	0
Annual Time Burden (Hours)	6,158	6,158	0
Annual Cost Burden (Dollars)	7,143	11,143	-4,000

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $90,404

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Cheryl Jordan 202 693-0289 [email protected]

Common Form ICR: No