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

Forms and Documents

Document Name	Status
Form LS-210 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 Form	Modified
SS for 1215-0031 (LS-202 and LS-210) April 10, 2007.doc Supporting Statement A	2007-08-22
DOL-ESA-15.pdf Supplementary Document	2007-07-25

IC Document Collections

IC ID	Document Title	Status
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 Form	Modified

ICR Details

OMB Control No: 1240-0003	ICR Reference No: 201003-1240-003
Status: Historical Active	Previous ICR Reference No: 200408-1215-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: 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
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/12/2010
	Date Received in OIRA: 03/12/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	36 Months From Approved
Responses	26,381	0	23,220
Time Burden (Hours)	6,595	0	5,835
Cost Burden (Dollars)	11,608	0	10,000

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Abstract: The LS-202 and LS-210 are used to report injuries, periods of disability, and medical treatment under the Longshore and Harbor Workers' Compensation Act.

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Authorizing Statute(s): US Code: 33 USC Chapter 18 Name of Law: Longshore and Harbor Worker's Compensation Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 20564	04/25/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 49319	08/28/2007
Did the Agency receive public comments on this ICR? No

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

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

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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	26,381	23,220	0	-60	3,221	0
Annual Time Burden (Hours)	6,595	5,835	0	-45	805	0
Annual Cost Burden (Dollars)	11,608	10,000	0	0	1,608	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: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: Burden has increased reflects an adjustment in the number of injuries reported under the Act. The burden decrease as a program change is because the LS-205 has been removed from this information collection. The operation and maintenance cost has increased from $10,000 to $11,607.64 which is an increase of $1,607.64 (rounded to $1,608.00) due to an increase in postage cost and the reporting under the Act.

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Annual Cost to Federal Government: $17,004

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

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Common Form ICR:  No

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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: 08/28/2007

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