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View Information Collection (IC) List
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1240-0014
ICR Reference No:
201509-1240-001
Status:
Historical Active
Previous ICR Reference No:
201506-1240-005
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/28/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/19/2015
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2017
01/31/2017
01/31/2017
Responses
130,036
0
130,036
Time Burden (Hours)
44,955
0
44,955
Cost Burden (Dollars)
41,174
0
41,257
Abstract:
The regulations and forms cover the submission of information relating to the processing of claims for benefits under the Longshore Act and extensions.
Authorizing Statute(s):
US Code:
33 USC 901 et seq.
Name of Law: Longshore and Harbor Workers' Compensation Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Final or interim final rulemaking
80 FR 12917
03/12/2015
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
78 FR 57416
09/18/2013
30-day Notice:
Federal Register Citation:
Citation Date:
78 FR 78389
12/26/2013
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
LS-204 , LS-200 , LS-201 , LS-513 , LS-267 , LS-203 , LS-262 , LS-274 , LS-271
Notice of Employee's Injury or Death
,
Report of Payments
,
Claimant's Statement
,
Employee's Claim for Compensation
,
Claim for Death Benefits
,
Application for Self-Insurance
,
Attending Physician's Supplementary Report
,
Report of Injury Experience of Insurance Carrier or Self-Insured Employer
,
Report of Earnings
ICR Summary of Burden
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
130,036
130,036
0
0
0
0
Annual Time Burden (Hours)
44,955
44,955
0
0
0
0
Annual Cost Burden (Dollars)
41,174
41,257
0
-83
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$252,544
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Cheryl Jordan 202 693-0289 jordan.cheryl@dol.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
10/19/2015
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