Request for Examination and/or Treatment

Forms and Documents

Document Name	Status
Form LS-1 Request for Examination and/or Treatment Form	Modified
OMB - Supporting Statement for 1215-0066 (LS-1) December 2007.doc Supporting Statement A	2008-04-17
33 USC, Chapter 18 Section 907.doc Supplementary Document	2008-01-08
DOL-ESA-15.pdf Supplementary Document	2008-01-08
20CFR702.419.pdf Supplementary Document	2008-01-08

IC Document Collections

IC ID	Document Title	Status
13713	Request for Examination and/or Treatment Form	Modified

ICR Details

OMB Control No: 1215-0066	ICR Reference No: 200801-1215-001
Status: Historical Active	Previous ICR Reference No: 200505-1215-002
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Request for Examination and/or Treatment
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/28/2008
	Date Received in OIRA: 04/25/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2011	36 Months From Approved	07/31/2008
Responses	75,000	0	101,250
Time Burden (Hours)	81,000	0	109,350
Cost Burden (Dollars)	3,558,000	0	41,000

---

Abstract: The LS-1 is used by employers to authorize medical treatment for injured workers and by physicians to report findings of physical examinations and treatment recommended.

---

Authorizing Statute(s): US Code: 33 USC Chapter 18, Section 907 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:
	73 FR 2947	01/16/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 22432	04/25/2008
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
Request for Examination and/or Treatment	LS-1	Request for Examination and/or Treatment

---

ICR Summary of Burden

	Total Approved	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	75,000	101,250	0	0	-26,250	0
Annual Time Burden (Hours)	81,000	109,350	0	0	-28,350	0
Annual Cost Burden (Dollars)	3,558,000	41,000	0	0	3,517,000	0

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: Burden has been reduced by 28,350 hours (109,350 previous burden hours – 81,000 current burden hours = 28,350 hours). This reduction in burden hours is the result of reduced reporting under the Act resulting in a reduction in the number of responses from the previous estimate of 101,250 responses to the current estimate of 75,000. A cost to the employer of $47.00 is applied per response for the physician’s time in performing each exam and completing the form. This cost, which was not accounted for in the last submission, has increased the cost burden by $3,525,000. Netted against a reduction in mailing cost of $8,000 due to fewer responses, the cost burden has increased by $3,517,000.

---

Annual Cost to Federal Government: $65,700

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/25/2008

---