View Information Collection (IC)

View Information Collection (IC)

IC 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	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 702.407 20 CFR 702.202 20 CFR 702.201

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-210	Employer's Supplementary Report of Accident or Occupational Illness	ls-210 2017.pdf	http://www.dol.gov/owcp/dlhwc/ls-210.pdf	Yes	No	Fillable Printable
Form and Instruction	LS-202	Employer's First Report of Injury or Occupational Illness	ls-202 2017.pdf	http://www.dol.gov/owcp/dlhwc/ls-202.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 58 FR 49599

Number of Respondents: 24,631	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	24,631	0	0	-4,198	0	28,829
Annual IC Time Burden (Hours)	6,158	0	0	-1,050	0	7,208
Annual IC Cost Burden (Dollars)	11,143	0	0	-1,147	0	12,290

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.