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Employment Standards Administration

Agency prefix 1215 · ESA · Federal forms and information collections.

Forms

OMB Number	Title
1215-0209	Notification of Employee Rights Under Federal Labor Laws
1215-0208	Work-Study Program of the Child Labor Regulations (WSP) Regulations 29 CFR Section 570.35b
1215-0207	Carrier's Report of Issuance of Policy
1215-0206	Death Gratuity
1215-0205	Form LM-30 Labor Organization Officer and Employee Report
1215-0204	Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions
1215-0203	EO 13201 - Notice of Employee Rights Concerning Payment of Union Dues or Fees
1215-0202	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
1215-0201	The Secretary of Labor, Exemplary Voluntary Effort (EVE), and Exemplary Public Interest Contribution (EPIC) Awards
1215-0200	Statement of Recovery Forms
1215-0199	Alternate Employment Information Request
1215-0197	Energy Employees' Occupational Illness Compensation Program Act forms (various)
1215-0196	Equal Opportunity Survey
1215-0195	Survey of Physicians Board Certified in Internal Medicine with Facilities
1215-0194	The NCPDP Universal Pharmacy Billing Form
1215-0193	Claimant Medical Reimbursement Form
1215-0192	Employment Under Special Certificates of Apprentices, Messengers and Learners (including Student Learners)
1215-0191	Airline Vacancy Listing
1215-0190	Nondisplacement of Qualified Workers Under Service Contracts
1215-0188	Labor Organization and Auxilliary Reports
1215-0187	Worker Information, Terms and Conditions of Employment
1215-0184	Service Contract Act Occupational Employment Questionnaire
1215-0183	PROCEDURES FOR THE HANDLING OF DISCRIMINATION COMPLAINTS UNDER FEDERAL EMPLOYEE PROTECTION STATUTES -- 29 CFR PART 24
1215-0182	Rehabilitation Action Report
1215-0181	THE FAMILY AND MEDICAL LEAVE ACT_-- 29 CFR PART 825
1215-0179	NOTICE TO BENEFICIARY (RO MONTHLY) NOTICE TO BENEFICIARY (RO MBO) NOTICE TO BENEFICIARY (TF MBO)
1215-0178	Claim for Reimbursement-Assisted Reemployment
1215-0177	Resubmission Turnaround Document
1215-0176	Uniform Health Insurance Claim Form -- UB-92
1215-0175	The Remedial Education Provisions of the Fair Labor Standards Act
1215-0174	PATIENT ADVOCATE PILOT QUESTIONNAIRE - PHYSICIAN INTERVIEW
1215-0173	REPRESENTATIVES PAYEE REPORT, REPRESENTATIVES PAYEE REPORT (PART 2), PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT
1215-0172	29 CFR 517 - TRAINING WAGE PROVISIONS OF THE FAIR LABOR STANDARDS AMENDMENTS OF 1989
1215-0171	Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor
1215-0170	APPLICATION OF THE EMPLOYEE POLYGRAPH PROTECTION ACT OF 1988-29 CFR PART 801
1215-0169	REPORTING AND EMPLOYMENT REQUIREMENTS FOR EMPLOYERS OF CERTAIN WORKERS EMPLOYED IN SEASONAL AGRICULTURAL SERVICES, 29 CFR PART 502
1215-0168	WORK-DAY REPORT
1215-0167	Notice of Recurrence of Disability and Claim for Continuation of Pay/Compensation
1215-0166	Request to be Selected as Payee -- CM-910
1215-0165	PERMISSIBLE HOURS OF EMPLOYMENT FOR BAT BOYS AND BAT GIRLS
1215-0163	Recordkeeping and Reporting Requirements: Construction
1215-0162	GENERAL REGULATIONS UNDER THE WALSH-HEALEY PUBLIC CONTRACTS ACT, 41 CFR PART 50-201.101(A)(2)(I) AND (II), 50-201.501, 50-201.604(A) AND (C)
1215-0161	Rehabilitation Maintenance Certificate
1215-0160	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
1215-0159	NOTICE OF INTENT TO EMPLOY HOMEWORKERS IN THE KNITTED OUTERWEAR INDUSTRY
1215-0158	Occupancy Certificate - Migrant and Seasonal Agricultural Worker Protection Act
1215-0157	GENERAL REGULATIONS UNDER THE WALSH-HEALEY PUBLIC CONTRACTS ACT 41 CFR PART 50-201.101(A)(2)(XI)
1215-0155	CLAIMS FOR COMPENSATION BY DEPENDENTS AND DEPENDENTS INFORMATION REPORTS (DEATH)
1215-0154	Claim for Continuance of Compensation
1215-0152	SURVEY OF OCCUPATIONAL WAGES AND EMPLOYEE BENEFITS IN THE CONSTRUCTION INDUSTRY, COBB COUNTY, GEORGIA
1215-0151	REQUEST FROM CLAIMANT FOR INFORMATION ON EARNINGS, DUAL BENEFITS, DEPENDENTS, AND THIRD-PARTY SETTLEMENT
1215-0150	SERVICE CONTRACT ACT RECORDKEEPING AND REPORTING REQUIREMENTS - 29 CFR PART 4
1215-0149	PAYROLL FORM
1215-0148	WAGE STATEMENT (ENGLISH AND SPANISH)
1215-0146	Housing Terms and Conditions For MSPA Workers
1215-0145	WORKER INFORMATION
1215-0144	Overpayment Recovery Questionnaire
1215-0143	SURVEY OF BLACK LUNG BENEFICIARIES
1215-0142	UNIFORM BILLING CLAIM FORM
1215-0141	SURVEY OF EXPENDITURES FOR EMPLOYEE COMPENSATION
1215-0140	Requests to Approve Conformed Wage Classifications and Unconventional Fringe Benefit Plans Under the Davis-Bacon and Related Acts and Contract Work Hours and Safety Standards Act
1215-0139	WAGE SURVEY OF TIPPED EMPLOYEES IN HOTELS AND RESTAURANTS
1215-0137	Provider Enrollment Form
1215-0136	Annual Report of Earnings
1215-0133	MEDICAL RECORDKEEPING REQUIREMENT
1215-0131	PREPARATION OF COMPLAINT FORM BY INDIVIDUAL COMPLAINTS
1215-0128	FARM LABOR CONTRACTOR REGISTRATION - 29 CFR 40.51, 40.52 AND 40.53
1215-0126	CONFORMANCE RECORD SERVICE CONTRACT ACT
1215-0124	MAINTENANCE OF RECEIPTS FOR BENEFITS PAID BY A COAL MINE OPERATOR (RECORD KEEPING REQUIREMENT)
1215-0122	Requirements of a Bona Fide Profit-Sharing Plan or Trust (29 CFR Part 549)
1215-0121	WORK EXPERIENCE AND CAREER EXPLORATION PROGRAMS, 29 CFR PART 570.35A
1215-0120	Waiver of Child Labor Provisions for Agricultural Employment of 10 and 11 Year Old Minors in Hand Harvesting of Short Season Crops -- 29 CFR Part 575
1215-0119	Requirements of a Bona Fide Thrift or Savings Plan (29 CFR Part 547) and Requirements of a Bona Fide Profit-Sharing Plan or Trust (29 CFR Part 549)
1215-0118	20 CFR 702.148 MAITENANCE OF RECORDS OF COMPENSATION PAYMENTS
1215-0117	20 CFR 702.111 MAINTENANCE OF RECORDS OF INJURY/ OCCUPATIONAL DISEASE
1215-0116	Notice of Law Enforcement Officer's Injury or Occupational Disease Notice of Law Enforcement Officer's Death
1215-0115	REPRESENTATIVE FEE REQUEST
1215-0114	PHYSICIAN INFORMATION FORM
1215-0113	CERTIFICATE OF MEDICAL NECESSITY (CMN)
1215-0112	Request for Earnings Information
1215-0110	A STUDY OF ACCOMMODATIONS PROVIDED TO HANDICAPPED EMPLOYEES BY FEDERAL CONTRACTORS
1215-0106	REQUESTS FOR MEDICAL REPORTS
1215-0105	Request for Employment Information
1215-0103	PHYSICIAN REPORTS, EVALUATIONS AND BILLS FOR SERVICES
1215-0101	NOTICE TO CARRIER OR SELF-INSURER EMPLOYER
1215-0097	SERVICE CONTRACT ACT SURVEY QUESTIONNAIRE
1215-0096	POLICIES AND PRACTICES OF INSURANCE CARRIERS AFFECTING APPLICANTS FOR GROUP INSURANCE
1215-0091	DECLARATION OF CITIZENSHIP - 29 CFR 40.51(P)
1215-0090	STANDARDS FOR DETERMINING COAL MINERS' DISABILITY DUE TO PNEUMOCONIOSIS
1215-0089	CLAIMANT'S STATEMENT
1215-0087	Survivor's Notification of Beneficiary's Death
1215-0086	ENERGY SECTOR FEDERAL INTERAGENCY TASK FORCE
1215-0085	Pre-Hearing Statement
1215-0084	REPORT OF CHANGES THAT MAY AFFECT YOUR DEPARTMENT OF LABOR BLACK LUNG PAYMENT
1215-0083	APPLICATION FOR FEDERAL CERTIFICATE OF AGE - 29 CFR PART 570.5(B)(1)
1215-0080	Application for Authority for an Institution on Higher Education to Employ its Full-time Students at Subminimum Wages Under Regulations Part 519
1215-0078	Representative Fee Request
1215-0076	APPLICATION FOR LUMP SUM AWARD
1215-0073	Application for Continuation of Death Benefits for Students
1215-0072	RESPONSES BY CONTRACTORS AND SUBCONTRACTORS TO COMPLIANCE REVIEWS BY OFCCP, EXCLUDING CONSTRUCTION
1215-0069	Survivor's Form for Benefits
1215-0068	REPORT OF PAYMENTS
1215-0067	Rehablitation Plan and Award
1215-0066	Request for Examination and/or Treatment
1215-0065	REPORT OF SECTION 10(H)(1) ADJUSTMENT PAYMENTS IN SUPPORT OF CLAIM FOR REIMBURSEMENT
1215-0064	NOTICES FROM RESPONSIBLE OPERATORS
1215-0063	NOTICE OF EMPLOYEE'S INJURY OR DEATH
1215-0062	APPLICATION FOR SELF-INSURANCE
1215-0061	STUDENT STATEMENT/SCHOOL CERTIFICATION
1215-0060	Request for State or Federal Workers' Compensation Information
1215-0059	Notice of Issuance of Insurance Policy
1215-0058	OPERATOR RESPONSE CM 970A AND OPERATOR CONTROVERSION FROM CM 970
1215-0057	Authorization for Release of Medical Information (Black Lung Benefits)
1215-0056	Comparability of Current Work to Coal Mine Employment
1215-0055	UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT
1215-0054	Medical Travel Refund Requst
1215-0053	WIFE'S CERTIFICATION OF MARRIAGE
1215-0052	MINERS' CLAIM FOR BENEFITS AND REIMBURSEMENT
1215-0051	Carrier's or Self-Insurer's Report to Deputy Commissioner
1215-0050	MAIL HAULER WAGE RATE SURVEY
1215-0048	APPLICATION FOR A CERTIFICATE TO EMPLOY LEARNERS AT A WAGE L ESS THAN THE APPLICABLE WAGE ORDER MINIMUM UNDER THE FLSA
1215-0046	Report to Construction Contractor's Wage Rates
1215-0045	ACCIDENT DATA ON SCHOOL BUS DRIVERS REPORT
1215-0038	APPLICATION FOR A FARM LABOR CONTRACTOR CERTIFICATE OF REGISTRATION
1215-0037	Application for Farm Labor Contractor or Farm Labor Contractor Employee Certificate of Registration
1215-0036	Vehicle Mechanical Inspection Report for Transportation Subject to DOT Requirements; Vehicle Mechanical Inspection Report for Transportation Subject to Department of Labor Safety Standards
1215-0034	AGREEMENT AND UNDERTAKING (FORM OWCP-1)
1215-0033	REPORT OF INJURY EXPERIENCE OF SELF-INSURED EMPLOYER
1215-0032	Applications for Authority to Employ Full-Time Students at Subminimum Wages in Retail/Service Establishments/Agriculture/Institutions of Higher Education
1215-0031	EMPLOYER'S SUPPLEMENTARY REPORT OF ACCIDENT OR OCCUPATIONAL ILLNESS
1215-0030	PAYROLL
1215-0028	WH-1: ECONOMICS SURVEY SCHEDULE WH-1 INST.: INSTRUCTIONS FOR COMPLETING WH-1
1215-0027	Certification of Funeral Expenses
1215-0024	NOTICE OF FINAL PAYMENT OR SUSPENSION OF COMPENSATION PAYMENTS
1215-0023	NOTICE TO THE DEPUTY COMMISSIONER THAT RIGHT TO COMPENSATION IS CONTROVERTED
1215-0022	Payment of Compensation Without Award
1215-0018	APPLICATION FOR SELF-INSURANCE AND FINANCIAL STATEMENT
1215-0017	RECORDS TO BE KEPT BY EMPLOYERS UNDER THE FSLA OF 1938, AS AMENDED (29 CFR 516)
1215-0016	EMPLOYEE PERSONAL INTERVIEW STATEMENT
1215-0013	HOMEWORKER HANDBOOK (ENGLISH, V.I., SPANISH)
1215-0012	APPLICATION FOR CERTIFICATE TO EMPLOY LEARNERS AT SUBMINIMUM WAGES
1215-0011	EMPLOYEE MAIL INTERVIEW FORM (ENGLISH AND SPANISH)
1215-0009	VERIFICATION OF DATE OF BIRTH (ENGLISH)
1215-0008	ESTABLISHMENT INFORMATION, SPANISH TRANSLATION
1215-0007	RECEIPT FOR PAYMENT OF BACK WAGES (ENGLISH & SPANISH)
1215-0006	WAGE TRANSCRIPTION AND COMPUTATION SHEET
1215-0005	Applications to Employ Special Industrial Homeworkers, Student-Learners, Workers with Disabilities
1215-0001	Employment Information Forms