View Information Collection Request (ICR) Package
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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:
1240-0014
ICR Reference No:
202012-1240-001
Status:
Historical Active
Previous ICR Reference No:
202001-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Administration of the Longshore and Harbor Workers' Compensation Act
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
02/16/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/15/2020
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2023
10/31/2023
10/31/2023
Responses
53,842
0
53,842
Time Burden (Hours)
20,752
0
20,752
Cost Burden (Dollars)
786
0
9,525
Abstract:
The regulations and forms cover the submission of information relating to the processing of claims for benefits under the Longshore Act and extensions. A new form, LS-272 (Application to Write Insurance) is added to this collection.
Authorizing Statute(s):
US Code:
33 USC 944
Name of Law: Longshore and Harbor Workers' Compensation A
US Code:
33 USC 939
Name of Law: Longshore and Harbor Workers' Compensation A
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:
85 FR 11397
02/27/2020
30-day Notice:
Federal Register Citation:
Citation Date:
85 FR 31228
05/22/2020
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
LS-272, LS-204 , LS-200 , LS-201 , LS-513 , LS-267 , LS-203 , LS-262 , LS-274 , LS-271
Notice of Employee's Injury or Death
,
Report of Payments
,
Claimant's Statement
,
Employee's Claim for Compensation
,
Claim for Death Benefits
,
Application for Self-Insurance
,
Attending Physician's Supplementary Report
,
Report of Injury Experience of Insurance Carrier or Self-Insured Employer
,
Report of Earnings
,
Application to write Longshore Insurance
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
53,842
53,842
0
0
0
0
Annual Time Burden (Hours)
20,752
20,752
0
0
0
0
Annual Cost Burden (Dollars)
786
9,525
0
-8,739
0
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:
Annual Cost to Federal Government:
$183,923
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?
No
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:
12/15/2020
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