Request for Examination and/or Treatment

ICR 201702-1240-001

OMB: 1240-0029

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Form
Modified
Supporting Statement A
2017-08-29
Supplementary Document
2011-02-17
Supplementary Document
2008-01-08
Supplementary Document
2008-01-08
ICR Details
1240-0029 201702-1240-001
Historical Active 201506-1240-009
DOL/OWCP
Request for Examination and/or Treatment
Extension without change of a currently approved collection   No
Regular
Approved without change 11/01/2017
Retrieve Notice of Action (NOA) 08/30/2017
  Inventory as of this Action Requested Previously Approved
11/30/2020 36 Months From Approved 10/31/2017
90,000 0 96,000
48,750 0 52,000
1,484,816 0 2,085,715

Form LS-1 is used by employers to authorize medical treatment for injured workers and by claimants to report findings of physical examinations and treatment recommended.

US Code: 33 USC 939(a) Name of Law: Longshore and Harbor Workers' Compensation Act
  
None

Not associated with rulemaking

  82 FR 17883 04/13/2017
82 FR 41288 08/30/2017
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 90,000 96,000 0 0 -6,000 0
Annual Time Burden (Hours) 48,750 52,000 0 0 -3,250 0
Annual Cost Burden (Dollars) 1,484,816 2,085,715 0 0 -600,899 0
No
No
There is a decrease of 6,000 responses (from 96,000 to 90,000) since the last clearance submission due to a decrease in reporting under the LHWCA. This has resulted in a corresponding reduction of 3,250 burden hours (52,000 to 48,750). There has been a decrease in the operation and maintenance costs from $2,085,715 to $1,484,816 due to the ability now to submit the form electronically. The cost reduction was slightly offset by the fact that the agency has taken on burden for the paper and printing costs of responding.

$35,271
No
    Yes
    Yes
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.
08/30/2017


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