View Information Collection (IC)

View Information Collection (IC)

IC Title:	Request for Examination and/or Treatment (Employee Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.419

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-1	Request for Examination and/or Treatment	Proposed LS-1.pdf	http://www.dol.gov/owcp/dlhwc/ls-1.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/GOVT-15	FR Citation: 67 FR 16870

Number of Respondents: 45,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 13 %

	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	45,000	0	0	-3,000	0	48,000
Annual IC Time Burden (Hours)	41,250	0	0	-2,750	0	44,000
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	10/01/2014

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