Information Collection Request
Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness
ICR 202312-1240-001 · 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⚠️ Notice: This information collection may be outdated.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-210 Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness |
Form | Modified | Repair queued |
 SUPPORTING STATEMENT2023LS202 JP JM final_MN_clean.docx |
Supporting Statement A | Uploaded 2024-01-29 | 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 | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0003 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202002-1240-002 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |