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Agenda
Reg Review
ICR
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 702.111
20 CFR 703.310
20 CFR 702.162
20 CFR 702.201
20 CFR 702.242
20 CFR 702.285
20 CFR 702.321
20 CFR 702.175
20 CFR 702.202
20 CFR 702.174
20 CFR 702.221
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.pdf
http://www.dol.gov/owcp/dlhwc/ls-201.pdf
Yes
No
Fillable Printable
Form
LS-513
Report of Payments
LS-513.pdf (DBA changes)3.pdf
http://www.dol.gov/owcp/dlhwc/LS-513.pdf
Yes
No
Fillable Printable
Form
LS-267
Claimant's Statement
LS-267.pdf
http://www.dol.gov/owcp/dlhwc/LS-267.pdf
Yes
No
Fillable Printable
Form
LS-203
Employee's Claim for Compensation
ls-203.pdf
http://www.dol.gov/owcp/dlhwc/ls-203.pdf
Yes
No
Fillable Printable
Form
LS-262
Claim for Death Benefits
ls-262.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.pdf
http://www.dol.gov/owcp/dlhwc/LS-271.pdf
Yes
No
Fillable Printable
Form
LS-204
Attending Physician's Supplementary Report
ls-204.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.pdf
http://www.dol.gov/owcp/dlhwc/LS-274.pdf
Yes
No
Fillable Printable
Form
LS-200
Report of Earnings
ls-200.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
0
0
130,036
Annual IC Time Burden (Hours)
44,955
0
0
5
0
44,950
Annual IC Cost Burden (Dollars)
46,866
0
0
887
0
45,979
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.