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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:
1240-0029
ICR Reference No:
201702-1240-001
Status:
Historical Active
Previous ICR Reference No:
201506-1240-009
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Request for Examination and/or Treatment
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/01/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/30/2017
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2020
36 Months From Approved
10/31/2017
Responses
90,000
0
96,000
Time Burden (Hours)
48,750
0
52,000
Cost Burden (Dollars)
1,484,816
0
2,085,715
Abstract:
Form LS-1 is used by employers to authorize medical treatment for injured workers and by claimants to report findings of physical examinations and treatment recommended.
Authorizing Statute(s):
US Code:
33 USC 939(a)
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:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
82 FR 17883
04/13/2017
30-day Notice:
Federal Register Citation:
Citation Date:
82 FR 41288
08/30/2017
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Request for Examination and/or Treatment (Employee Burden)
LS-1
Request for Examination and/or Treatment
Request for Examination and/or Treatment (Employer Burden)
LS-1
Request for Examination and/or Treatment
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
90,000
96,000
0
0
-6,000
0
Annual Time Burden (Hours)
48,750
52,000
0
0
-3,250
0
Annual Cost Burden (Dollars)
1,484,816
2,085,715
0
0
-600,899
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:
There is a decrease of 6,000 responses (from 96,000 to 90,000) since the last clearance submission due to a decrease in reporting under the LHWCA. This has resulted in a corresponding reduction of 3,250 burden hours (52,000 to 48,750). There has been a decrease in the operation and maintenance costs from $2,085,715 to $1,484,816 due to the ability now to submit the form electronically. The cost reduction was slightly offset by the fact that the agency has taken on burden for the paper and printing costs of responding.
Annual Cost to Federal Government:
$35,271
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
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:
08/30/2017
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