View Information Collection (IC)
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ICR
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 702.201
20 CFR 702.202
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.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 (2).pdf
http://www.dol.gov/owcp/dlhwc/ls-202.pdf
Yes
Yes
Fillable Fileable
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 16865
Number of Respondents:
28,829
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
1 %
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
28,829
0
0
7,746
0
21,083
Annual IC Time Burden (Hours)
7,208
0
0
1,937
0
5,271
Annual IC Cost Burden (Dollars)
14,126
0
0
4,217
0
9,909
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.