ESA (EMPLOYMENT STANDARDS ADMINISTRATION) Forms in Word

Form

Description

Price

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EE 1

Claim for Benefits under Energy Employees Occupational Illness Compensation Program Act

LS 1

Request for Examination and/or Treatment

OWCP 1

Agreement and Undertaking

WH 1

Economic Survey Schedule

WD 10

Report of Construction Contractor's Wage Rates

CA 1027

Request for Employment Information

CA 1031

CA- 1031- Form Letter Requesting More Information

CA 1032

Request for Information on Earnings, Dual Benefits, Dependents   and Third Party Settlements

CA 1074

Evidence Required in Support of Dependency Claim

CA 1087

FECA Medical Report Forms, Claim for Compensation

CA 1090

FECA Medical Report Forms, Claim for Compensation

CM 1093

Affidavit of Deceased Miner's Condition

CA/EN 1108

Statement of Recovery Forms

EB/EN 1108

Statement of Recovery Forms

CA/EN 1122

Statement of Recovery Forms

CM 1159

Report of Arterial Gas Study

OWCP 1168

Provider Enrollment Form

CA 12

Claim for Continuance of Compensation Under the Federal Empoyees' Compensation Act

CA 1303

FECA Medical Report Forms, Claim for Compensation

CA 1305

FECA Medical Report Forms, Claim for Compensation

CA 1331

FECA Medical Report Forms, Claim for Compensation

CA 1332

FECA Medical Report Forms, Claim for Compensation

WH 14

Application for Federal Certificate of Age

OWCP 1500

Health Insurance Claim Form

CA 16

FECA Medical Report Forms, Claim for Compensation

OWCP 16

Rehabilitation Plan and Award

CA 17

Duty Status Report

OWCP 17

Rehabilitation Maintenance Certificate

LS 18

Pre-Hearing Statement

EE 2

Claim for Survivor Benefits under Energy Employees Occupational Illness Compensation Program Act

WH 2

Application for Special Industrial Homeworker's Certificate

CA 20

Attending Physician Report

EE 20

Energy Employee Occupational Illness Compensation Program Act Forms (various)

OWCP 20

Overpayment Recovery Questionnaire

CM 200

Maintenance of Receipt for Benefits Paid by a Coal Mine Operator

LS 200

Report of Earnings

WH 200

Applications for Authority to Employ Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 CFR Part 519

LS 201

Notice of Employee's Injury or Death

WH 201

Application for Authority for an Institution on Higher Education to Employ its Full-time Students at Subminimum Wages Under Regulations 29 CFR Part 519

LS 202

Employer's First Report of Injury or Occupational Disease

WH 202

Applications for Authority to Employ Six or Fewer Full-Time Students at   Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 25 CFR Part 519

LS 203

Employee's Claim for Compensation

LS 204

Attending Physician's Supplementary Report

LS 205

Physician's Report on Impairment of Vision

WH 205

Application for Authorization to Employ a Student-Learner at Subminimum Wages

LS 206

Payment of Compensation Without Award

LS 207

Notice of Controversion of Right to Compensation

LS 208

Notice of Final Payment or Suspension of Compensation Benefits

WH 209

Employment Under Special Certificate of Apprentices, Messengers   and Learners (including Student Learners)

LS 210

Employer's Supplementary Report of Accident or Occupational Illness

CA 2231

Claim for Reimbursement-Assisted Reemployment

WH 226

Application for Authority to Employ Workers with Disabilities at Special Minimum Wages

WH 226A A

Supplemental Data Sheet for Application for Authority to Employ Workers with Disabilities at Special Minimum Wages

LS 262

Claim for Death Benefits

LS 265

Certification of Funeral Expenses

LS 266

Application for Continuation of Death Benefit for Student (under the Longshore and Harbor Workers' Compensation Act)

LS 267

Claimant's Statement

LS 271

Application for Self-Insurance

LS 274

Report of Injury Experience of Self-Insured Employer

CM 2907

Report of Ventilator Study

CM 2970

Operator Response to Schedule for Submission of Additional Evidence

CM 2970a A

Operator Response to   Response to Notice of Claim

CA 2a A

Notice of Recurrence

EE 3

Employment History under the Energy Employees Occupational Illness Compensation Program Act

WH 3 ESPANOL

Employment Information Forms

WH 3 English

Employment Information Forms

WH 347

Optional Use Payroll Form Under the Davis-Bacon Act

WH 380

Certification of Health Care Provider

WH 381

Employer Response to Employee Request for Family or Medical Leave

EE 4

Employment History Affidavit for Claim Under the Energy Employees Occupational Illness Compensation Program Act

LS 426

Request for Earnings Information

OWCP 44

Rehabilitation Action Report

WH 46

Application for Certificate to Employ Homeworkers

CA 5

Claim for Compensation by Widow, Widower, and/or Children

WH 501 ESPANOL

Wage Statement (Spanish)

WH 501 English

Wage Statement

LS 513

Report of Payments

WH 514 English

Vehicle Mechanical Inspection Report for Transportation Subject to DOT Requirements

WH 514a ESPANOL

Vehicle Mechanical Inspection Report for Transportation Subject to DOL Safety Standards

WH 520

Occupancy Certificate - Migrant and Seasonal Agricultural Worker   Protection Act

WH 521

Housing Terms and Conditions

WH 530

Application for Farm Labor Contractor or Farm Labor Contractor   Employee Certificate of Registration- Migrant and Seasonal Agricultural Worker Protection Act

CA 5b B

Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren

CM 623

Representative Payee Report

CM 623s S

Representative Payee Report

CA 7

FECA Medical Report Forms, Claim for Compensation

EE 7

Medical Requirements under the Energy Employees Occupational Illness Compensation Program Act

CA 721

Notice of Law Enforcement Officer's Injury or Occupational Disease

CA 722

Notice of Law Enforcement Officer's Death   

CM 787

Physician's/Medical Officer's Report

CM 893

Certificate of Medical Necessity

EE 9

Energy Employee Occupational Illness Compensation Program Act   Forms (various)

CM 905

Request for State or Federal Workers' Compensation Information

CM 907

Report of Ventilator Study

CM 908

Notice of Termination, Suspension, Reduction or Increase in   Benefit Payments

CM 910

Request to be Selected as Payee

CM 911

Miner's Claim for Benefits Under the Black Lung Benefits Act

CM 911a A

Employment History

CM 912

Survivor's Form for Benefits Under the Black Lung Benefits Act

CM 913

Description of Coal Mine Work and Other Employment

CA 915

Claimant for Medical Reimbursement

CM 915

Miner Medical Reimbursement Form

CM 918

Coal Mine Employment Affidavit

OWCP 92(UB-92)

Uniform Health Insurance Claim Form

CM 921

Notice of Issuance of Insurance Policy

CM 929

Report of Changes That May Affect Your Black Lung Benefits

CM 933

Roentgenograhic Interpretation

CM 933b B

Roentgenographic Quality Rereading

CM 936

Authorization for Release of Medical Information (Black Lung Benefits)

OWCP 957

Medical Travel Refund Request

CM 970

Operator Controversion

CM 970a A

Operator Response

CM 972

Application for Approval of a Representative's Fee in Black Lung Claim Proceeding Conducted by The U.S. Department of Labor

CM 981

Certification by School Official

CM 988

Medical History and Examination for Coal Mine Worker's Pneumoconoisis

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