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

ICR 202002-1240-002

OMB: 1240-0003

Federal Form Document

ICR Details
1240-0003 202002-1240-002
Received in OIRA 201611-1240-004
DOL/OWCP
Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness
Revision of a currently approved collection   No
Regular 06/25/2020
  Requested Previously Approved
36 Months From Approved 01/31/2021
24,631 24,631
6,158 6,158
7,143 11,143

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

  85 FR 19777 04/08/2020
85 FR 37691 06/23/2020
No

  Total Request 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 24,631 0 0 0 0
Annual Time Burden (Hours) 6,158 6,158 0 0 0 0
Annual Cost Burden (Dollars) 7,143 11,143 0 -4,000 0 0
No
No

$90,404
No
    Yes
    Yes
No
No
No
No
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.
06/25/2020


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