U.S. Department of Labor

Office of Workers' Compensation Programs Employer's Supplementary Report of

Accident or Occupational Illness

Notice: This Report should be filed promptly with the District Director in every case in which (1) Form LS-202 

does not show date injured employee returned to work, and (2) each time injured employee has returned to 

work and later becomes disabled for work (33 U.S.C.930(b) if the information is not already reported via Form 

LS-208. If the employee was disabled for work more than 3 days, compensation payments should be reported 

on Form LS-208. Medical reports must be sent to the District Director promptly following first treatment and 

thereafter while treatment continues. Please type or print all information. (if additional space is needed, use 

back of form.) The information will be used to determine entitlement to benefits. This report must be filed with 

the U.S. Department of Labor, Office of Workers’ Compensation Programs, Division of Longshore and Harbor 

Workers’ Compensation by electronic submission via OWCP web portal or Central Mail Receipt Site. 

OMB No. 1240-0003

1. OWCP No.

2. Carrier's No.

3. Name of injured employee (First, middle initial, last) 4. Date of accident (Month, day, year)

5. Address of injured employee (Number and Street, City, State, ZIP code) 6. Name and address of your insurance carrier

7. Initial Period of Disability (Use Inclusive Dates for a and b)

a. From (Month, day, year) b. Through (Month, day, year) c. Date returned to work (Month, day, year)

8. If this report covers a period of disability after the date shown in item 7c. state each subsequent period of disability. Use inclusive dates for

a. and b.

a. From (Month, day, year) b. Through (Month, day, year) c. Date returned to work (Month, day, year)

9. Did employee receive medical attention?

Yes - Give dates, names and addresses of doctors and hospitals providing treatment. b. No - Explain a.

10. Was employee treated by his or her choice of physician?

Yes No

11. Was form LS-1 given to employee when injury was reported to you?

Yes No

12. Name of employer 13. Employer's address (Number and Street, City, State, ZIP code)

14. Signature of person authorized to sign 15. Name, official title and phone number of person signing 16. Date of report

for employer (month, day, year)

Public Burden Statement

valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of

information. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. (33 U.SC.930(b)). Send

comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

Form LS-210

Rev. Nov 2020

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a

U.S. Department of Labor, 200 Constitution Avenue, NW, Room S-3229, Washington, D.C. 20210, and reference the OMB Control Number.

Expires: 2/29/2024
Form LS-210

Rev. Nov 2020

PRIVACY ACT OF 1974 NOTICE 

 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' 

Compensation Act, as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of 

the U.S. Department of Labor, which receives and maintains personal information on claimants. (2) Information which the Office has will be used to 

determine eligibility for the amount of benefits payable under the LHWCA. (3) Information may be given to the claimant or his/her representative. (4) 

Information may be given to physicians and other medical service providers for use in providing treatment or medical/vocational rehabilitation, making 

evaluations and for other purposes relating to the medical management of the claim. (5) Information may be given to the Department of Labor's Office of 

Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render decisions with respect to the claim or 

other matter arising in connection with the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to 

obtain information relevant to a decision under the LHWCA, to determine whether benefits are being or have been paid properly, and, where appropriate, 

to pursuesalary/administrative offset and debt collection actions required or permitted by law.

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