View Information Collection (IC)

View Information Collection (IC)

IC Title:	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	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 702.174 20 CFR 702.242 20 CFR 702.285 20 CFR 702.321 20 CFR 702.175 20 CFR 702.202 20 CFR 702.221 20 CFR 702.201 20 CFR 702.111 20 CFR 703.310 20 CFR 702.162

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-201	Notice of Employee's Injury or Death	ls-201 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-201.pdf	Yes	No	Fillable Printable
Form	LS-513	Report of Payments	LS-513.pdf		No		Paper Only
Form	LS-267	Claimant's Statement	LS-267 dev.pdf	http://www.dol.gov/owcp/dlhwc/LS-267.pdf	Yes	No	Printable Only
Form	LS-203	Employee's Claim for Compensation	ls-203 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-203.pdf	Yes	No	Fillable Printable
Form	LS-262	Claim for Death Benefits	ls-262 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-262.pdf	Yes	No	Fillable Printable
Other-Recordkeeping			ESA 100.doc		No		Paper Only
Form	LS-271	Application for Self-Insurance	LS-271 dev.pdf	http://www.dol.gov/owcp/dlhwc/LS-271.pdf	Yes	No	Fillable Printable
Form	LS-204	Attending Physician's Supplementary Report	ls-204 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-204.pdf	Yes	No	Fillable Printable
Form	LS-274	Report of Injury Experience of Insurance Carrier or Self-Insured Employer	LS-274 dev.pdf	http://www.dol.gov/owcp/dlhwc/LS-274.pdf	Yes	No	Fillable Printable
Form	LS-200	Report of Earnings	ls-200 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-200.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/ESA-15	FR Citation: 67 FR 16886

Number of Respondents: 130,036	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 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	130,036	0	0	-45,338	0	175,374
Annual IC Time Burden (Hours)	44,950	0	0	-21,594	0	66,544
Annual IC Cost Burden (Dollars)	45,979	0	0	-20,608	0	66,587

Documents for IC

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.