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

ICR 201611-1240-004

OMB: 1240-0003

Federal Form Document

ICR Details
1240-0003 201611-1240-004
Active 201506-1240-006
DOL/OWCP
Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness
Extension without change of a currently approved collection   No
Regular
Approved without change 06/16/2017
Retrieve Notice of Action (NOA) 03/08/2017
  Inventory as of this Action Requested Previously Approved
06/30/2020 36 Months From Approved 06/30/2017
24,631 0 28,829
6,158 0 7,208
11,143 0 12,290

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 930 Name of Law: Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  81 FR 84622 11/23/2016
82 FR 13013 03/08/2017
No

  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 24,631 28,829 0 0 -4,198 0
Annual Time Burden (Hours) 6,158 7,208 0 0 -1,050 0
Annual Cost Burden (Dollars) 11,143 12,290 0 0 -1,147 0
No
No
The operation and maintenance cost has been decreased by $2,983 from $14,126.00 to $11,143.06 due to a decrease in the number of claims reported under the Act and the recent technology advancements allowing for the option to submit the forms electronically.

$18,995
No
No
No
No
No
Uncollected
Cheryl Jordan 202 693-0289 jordan.cheryl@dol.gov

  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.
03/08/2017


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