View Information Collection (IC)

View Information Collection (IC)

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 703.310 20 CFR 702.162 20 CFR 702.242 20 CFR 702.175 20 CFR 702.174 20 CFR 702.321 20 CFR 702.285 20 CFR 702.202 20 CFR 702.221 20 CFR 702.201 20 CFR 702.111

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-201 proposed Notice of Employee's Injury or Death LS-201 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/ls-201.pdf Yes No Fillable Printable
Form LS-513 proposed Report of Payments LS-513 proposed.pdf No   Paper Only
Form LS-267 proposed Claimant's Statement LS-267 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/LS-267.pdf Yes No Printable Only
Form LS-203 proposed Employee's Claim for Compensation LS-203 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/ls-203.pdf Yes No Fillable Printable
Form LS-262 proposed Claim for Death Benefits LS-262 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/ls-262.pdf Yes No Fillable Printable
Other-Recordkeeping ESA 100.doc No   Paper Only
Form LS-271 proposed Application for Self-Insurance LS-271 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/LS-271.pdf Yes No Fillable Printable
Form LS-204 proposed Attending Physician's Supplementary Report ls-204 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/ls-204.pdf Yes No Fillable Printable
Form LS-274 proposed Report of Injury Experience of Insurance Carrier or Self-Insured Employer ls-274 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/LS-274.pdf Yes No Fillable Printable
Form LS-200 proposed Report of Earnings ls-200 proposed.pdf http://www.dol.gov/esa/owcp/dlhwc/ls-200.pdf Yes No Fillable Printable

Workforce Management Training and Employment

DOL/ESA-15  58 FR 49599

175,374 0
   
Individuals or Households
 
   0 %

  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 175,374 0 0 -6,694 0 182,068
Annual IC Time Burden (Hours) 66,544 0 0 -4,832 0 71,376
Annual IC Cost Burden (Dollars) 66,587 0 0 1,587 0 65,000

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.