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Forms | U.S. Department of Labor
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These are the most frequently requested U.S. Department of Labor forms. You can complete some forms online, while you can download and print all others.
5500 Series
(Form Number - 5500; Agency - Employee Benefits Security Administration)
Administrative Subpoena to Appear & Testify at a Deposition
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Administrative Subpoena to Appear & Testify at a Hearing
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Administrative Subpoena to Produce Documents, Information or Objects, or to Permit Inspection of Premises
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Agreement and Activities Report
(Form Number - LM-20; Agency - Office of Labor-Management Standards)
Agreement and Undertaking (Self-Insured Employer)
(Form Number - OWCP-01; Agency - Office of Workers' Compensation Programs)
Agreement and Undertaking (Insurance Carrier)
(Form Number - LS-275ic; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Agreement and Undertaking (Self-Insured Employer)
(Form Number - LS-275si; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Agreement to Mediate
Form Number - N/A; Agency - Office of Administrative Law Judges)
Agricultural and Food Processing Clearance Order
(Form Number - 790; Agency - Employment and Training Administration)
Appeal Form
(Form Number - AB-1; Agency - Employees' Compensation Appeals Board)
Application for Alien Employment Certification - Part A
(Form Number - 750A; Agency - Employment and Training Administration)
Application for Alien Employment Certification - Part B
(Form Number - 750B; Agency - Employment and Training Administration)
Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor
(Form Number - CM-972; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Application for Authority to Employ Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519
(Form Number - WH-200; Agency - Wage and Hour Division)
Application for Authority to Employ Six or Fewer Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519
(Form Number - WH-202; Agency - Wage and Hour Division)
Application for Certificateto Employ Homeworkers
(Form Number - WH-46; Agency - Wage and Hour Division)
Application for Continuation of Death Benefit for Student
(Form Number - LS-266; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Application for Permanent Employment Certification
(Form Number - 9089; Agency - Employment and Training Administration)
Application for Prevailing Wage Determination
(Form Number - 9141; Agency - Employment and Training Administration)
Application for Prevailing Wage Determination
(Form Number - 9141C; Agency - Employment and Training Administration)
Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart
(Form Number - LS-276; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Application for Self-Insurance instructions
(Form Number - LS-271; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Application for Special Industrial Homeworker Certificate
(Form Number - WH-2; Agency - Wage and Hour Division)
Application For Special Relief Fund
(Form Number - LS-5; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Application to Employ Student-Learners at Subminimum Wages
(Form Number - WH-205; Agency - Wage and Hour Division)
Application to write Longshore Insurance (Carriers)
(Form Number - LS-272; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Approval of Compromise of Third Person Cause of Action
(Form Number - LS-33; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Attending Physician's Report
(Form Number - CA-20; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
en español
:
Informe del médico tratante (Número de formulario - CA-20; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
Attending Physician's Supplementary Report
(Form Number - LS-204; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Attorney Fee Approval Request
(Form Number - LS-4; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Authorization For Release Of Medical Information (Black Lung Benefits)
(Form Number - CM-936; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Black Lung Benefits Act Evidence Summary Form
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Carrier's Report of Issuance of Policy (formerly Card Report of Insurance)
(Form Number - LS-570; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Certificate of Electrical/Noise Training
(Form Number - 5000-1; Agency - Mine Safety and Health Administration)
Certificate of Medical Necessity
(Form Number - CM-893; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Certificate of Physical Qualification for Mine Rescue Work
(Form Number - 5000-3; Agency - Mine Safety and Health Administration)
Certificate of Training
(Form Number - 5000-23; Agency - Mine Safety and Health Administration)
Certificate of Training Form
(Form Number - WH-5; Agency - Wage and Hour Division)
Certificates of Achievement in Safety
(Form Number - N/A; Agency - Mine Safety and Health Administration)
Certification by School Official
(Form Number - CM-981; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Certification of Funeral Expenses
(Form Number - LS-265; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim for Compensation
(Form Number - CA-7; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim for Compensation by Parents, Brothers, Sisiters, GrandParents, or GrandChildren
(Form Number - CA-5b; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim for Compensation by Widow, Widower, and/or Children
(Form Number - CA-5; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim For Continuance of Compensation Under the Federal Employees' Compensation Act
(Form Number - CA-12; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim for Death Benefits
(Form Number - LS-262; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim For Medical Reimbursement
(Form Number - OWCP-915; Agency - Office of Workers' Compensation Programs)
Claim for Reimbursement Assisted Reemployment
(Form Number - CA-2231; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
(Form Number - CA-278; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity
(Form Number - CA-41; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Claimant's Statement
(Form Number - LS-267; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Commutation Application
(Form Number - LS-6; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Complaint/Apparent Violation Form
(Form Number - 8429; Agency - Employment and Training Administration)
Contractor ID Request
(Form Number - 7000-52; Agency - Mine Safety and Health Administration)
CW-1 Application for Temporary Employment Certification
(Form Number - 9142C; Agency - Employment and Training Administration)
DBRA Certified Payroll Form
(Form Number - WH-347; Agency - Wage and Hour Division)
DBRA Report of Construction Contractor’s Wage Rates
(Form Number - WH-10; Agency - Wage and Hour Division)
Description Of Coal Mine Work and Other Employment
(Form Number - CM-913; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a
(Form Number - CA-40; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Domestic Agricultural In- Season Wage Report
(Form Number - 232; Agency - Employment and Training Administration)
Domestic Agricultural In-season Wage Finding Process
(Form Number - 385; Agency - Employment and Training Administration)
Duty Status Report
(Form Number - CA-17; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
en español
:
Informe de estado de servicio (Número de formulario - CA-17; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
Electrically Operated Equipment Field Approval Application (Coal Only)
(Form Number - 2000-38; Agency - Mine Safety and Health Administration)
Electronic Training Plan Advisor
(Form Number - N/A; Agency - Mine Safety and Health Administration)
Employee's Claim
(Form Number - EE-1; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
Employee's Claim for Compensation
(Form Number - LS-203; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Employer Report
(Form Number - LM-10; Agency - Office of Labor-Management Standards)
Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage Determination Request Based on a Non-OES Survey
(Form Number - 9165; Agency - Employment and Training Administration)
Employer's First Report of Injury or Occupational Illness
(Form Number - LS-202; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Employer's Supplementary Report of Accident or Occupational Illness
(Form Number - LS-210; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Employers’ Attestation to Use Alien Crewmembers for Longshore Activities in the State of Alaska
(Form Number - 9033-A; Agency - Employment and Training Administration)
Employers’ Attestation to Use Alien Crewmembers for Longshore Activities in U.S. Ports Form ETA 9033
(Form Number - 9033; Agency - Employment and Training Administration)
Employment History
(Form Number - CM-911a; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Employment History
(Form Number - EE-3; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
Employment History Affidavit
(Form Number - EE-4; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
EPPA Notice to Examinee
(Form Number - WH-1481; Agency - Wage and Hour Division)
Evidence Required in Support of a Claim for Occupational Disease
(Form Number - CA-35; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Federal Contractor Discrimination Complaint
(Form Number - N/A; Agency - Office of Federal Contract Compliance Programs)
Federal Contractor Reporting - Veteran Hiring
(Form Number - VETS-4212; Agency - Veterans' Employment and Training Service)
Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
(Form Number - CA-1; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
FMLA Certification for Serious Injury or Illness of a Veteran for Wage and Hour Division Military Caregiver Leave
(Form Number - WH-385V; Agency - Wage and Hour Division)
FMLA Certification for Serious Injury orIllness of Covered Servicemember -- for Military Family Leave
(Form Number - WH-385; Agency - Wage and Hour Division)
FMLA Certification of Health Care Providerfor Employee’s Serious Health Condition
(Form Number - WH-380-E; Agency - Wage and Hour Division)
This form can't be completed online. It can be downloaded and completed with Adobe's free Acrobat Reader.
Use when a leave request is due to the medical condition of the employee.
FMLA Certification of Health Care Providerfor Family Member’s Serious Health Condition
(Form Number - WH-380-F; Agency - Wage and Hour Division)
This form can't be completed online. It can be downloaded and completed with Adobe's free Acrobat Reader.
Use when a leave request is due to the medical condition of the employee’s family member.
FMLA Certification of Qualifying Exigency For Military Family Leave
(Form Number - WH-384; Agency - Wage and Hour Division)
FMLA Designation Notice
(Form Number - WH-382 ; Agency - Wage and Hour Division)
FMLA Notice of Eligibility and Rights & Responsibilities
(Form Number - WH-381; Agency - Wage and Hour Division)
Foreign Labor Certification Quarterly Activity Report
(Form Number - 9127; Agency - Employment and Training Administration)
H-1B Nonimmigrant Information
(Form Number - WH-4; Agency - Wage and Hour Division)
H-2A Application for Temporary Employment Certification
(Form Number - 9142A; Agency - Employment and Training Administration)
H-2B Application for Temporary Employment Certification
(Form Number - 9142B; Agency - Employment and Training Administration)
Hazardous Condition Complaint
(Form Number - N/A; Agency - Mine Safety and Health Administration)
Health Activity Certification or Hoisting Engineers Qualification Request
(Form Number - 5000-41; Agency - Mine Safety and Health Administration)
Health Insurance Claim Form
(Form Number - OWCP-1500; Agency - Office of Workers' Compensation Programs)
Higher Education to Employ its Full-time Students at Subminimum Wages Under Regulations 29 C.F.R. Part 519
(Form Number - WH-201; Agency - Wage and Hour Division)
Homeworker Handbook
(Form Number - WH-75; Agency - Wage and Hour Division)
Homeworker Handbook (Spanish)
(Form Number - WH-75; Agency - Wage and Hour Division)
Injury & Illness Recordkeeping Forms
(Form Numbers - 300, 300A, 301; Agency - Occupational Safety and Health Administration)
Inspector General Hotline
(Form Number - N/A; Agency - Office of Inspector General)
Instructions For Completion of Form CM-921
(Form Number - CM-921; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Labor Organization Annual Report
(Form Number - LM-2; Agency - Office of Labor-Management Standards)
Labor Organization Annual Report
(Form Number - LM-3; Agency - Office of Labor-Management Standards)
Labor Organization Annual Report
(Form Number - LM-4; Agency - Office of Labor-Management Standards)
Labor Organization Information Report
(Form Number - LM-1; Agency - Office of Labor-Management Standards)
Labor Organization Officer and Employee Report
(Form Number - LM-30; Agency - Office of Labor-Management Standards)
LCA Online Application
(Form Number - 9035; Agency - Employment and Training Administration)
Leave Buy Back (LBB) Worksheet/Certification and Election
(Form Number - CA-7b; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Legal Identification Report
(Form Number - 2000-7; Agency - Mine Safety and Health Administration)
Letter to Dependants to Verify Claimant Support
(Form Number - CA-1031; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Letter to Parents in Death Claim Development
(Form Number - CA-1074; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LHWCA Prehearing Statement Form
(Form Number - N/A; Agency - Office of Administrative Law Judges)
LHWCA Uniform Stipulations Form
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Manage/Update Diesel Inventory
(Form Number - N/A; Agency - Mine Safety and Health Administration)
Mechanical Power Presses Injury Form
(Form Number - N/A; Agency - Occupational Safety and Health Administration)
Medical History and Examination for Coal Mine Workers' Pneumoconiosis
(Form Number - CM-988; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Medical Travel Refund Request
– Mileage (Form Number - OWCP-957A; Agency - Office of Workers' Compensation Programs)
Medical Travel Refund Request
– Expenses (Form Number - OWCP-957B; Agency - Office of Workers' Compensation Programs)
Mine Accident, Injury and Illness Report
(Form Number - 7000-1; Agency - Mine Safety and Health Administration)
Mine ID Request
(Form Number - 7000-51; Agency - Mine Safety and Health Administration)
Miner's Claim For Benefits Under The Black Lung Benefits Act
(Form Number - CM-911; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
MSPA Application for a Farm Labor Contractor or Farm Labor ContractorEmployee Certificate of Registration
(Form Number - WH-530; Agency - Wage and Hour Division)
MSPA Application for a Farm Labor Contractor or Farm Labor ContractorEmployee Certificate of Registration (Spanish)
(Form Number - WH-530; Agency - Wage and Hour Division)
MSPA Doctor’s Certificate
(Form Number - WH-515; Agency - Wage and Hour Division)
MSPA Housing Occupancy Certificate
(Form Number - WH-520; Agency - Wage and Hour Division)
MSPA Housing Terms and Conditions
(Form Number - WH-521; Agency - Wage and Hour Division)
MSPA Vehicle Mechanical Inspection Report for Transportation Subjectto Department of Transportation Requirements
(Form Number - WH-514; Agency - Wage and Hour Division)
MSPA Wage Statement
(Form Number - WH-501; Agency - Wage and Hour Division)
MSPA Wage Statement (Spanish)
(Form Number - WH-501; Agency - Wage and Hour Division)
MSPA Worker Information – Terms of Employment
(Form Number - WH-516; Agency - Wage and Hour Division)
MSPA Worker Information – Terms of Employment (Haitian Creole)
(Form Number - WH-516; Agency - Wage and Hour Division)
MSPA Worker Information – Terms of Employment (Spanish)
(Form Number - WH-516; Agency - Wage and Hour Division)
Multiple Employer Welfare Arrangements (MEWAs) Annual Report
(Form Number - M-1; Agency - Employee Benefits Security Administration)
Notice of Controversion of Right to Compensation
(Form Number - LS-207; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Employee's Injury or Death
(Form Number - LS-201; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Final Payment or Suspension of Compensation Payments
(Form Number - LS-208; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Law Enforcement Officer's Death
(Form Number - CA-722; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Law Enforcement Officer's Injury Or Occupational Disease
(Form Number - CA-721; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Occupational Disease and Claim for Compensation
(Form Number - CA-2; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Recurrence
(Form Number - CA-2a; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Notice of Termination, Suspension, Reduction or Increase in Benefit Payments
(Form Number - CM-908; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity
(Form Number - CA-42; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Official Supervisor's Report of Employee's Death
(Form Number - CA-6; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Operator Response to Notice of Claim
(Form Number - CM-2970a; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Operator Response to Schedule for Submission of Additional Evidence
(Form Number - CM-2970; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Operator’s Annual Certification of Mine Rescue Teams Qualifications
(Form Number - 2000-224; Agency - Mine Safety and Health Administration)
Overpayment Recovery Questionnaire
(Form Number - OWCP-20; Agency - Office of Workers' Compensation Programs)
Physician's/Medical Officer's Statement
(Form Number - CM-787; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Pre-Hearing Statement
(Form Number - LS-18; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Provider Enrollment form
(Form Number - OWCP-1168; Agency - Office of Workers' Compensation Programs)
Quarterly Mine Employment and Coal Production Report
(Form Number - 7000-2; Agency - Mine Safety and Health Administration)
Receipts and Disbursements Report
(Form Number - LM-21; Agency - Office of Labor-Management Standards)
Record of Individual Exposure to Radon Daughters
(Form Number - 4000-9; Agency - Mine Safety and Health Administration)
Rehabilitation Action Report
(Form Number - OWCP-44; Agency - Office of Workers' Compensation Programs)
Rehabilitation Maintenance Certificate
(Form Number - OWCP-17; Agency - Office of Workers' Compensation Programs)
Rehabilitation Plan And Award
(Form Number - OWCP-16; Agency - Office of Workers' Compensation Programs)
Report Commencement/Closure of Operation – Metal and Nonmetal Mines
(Form Number - N/A; Agency - Mine Safety and Health Administration)
Report of Arterial Blood Gas Study
(Form Number - CM-1159; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Report of Changes That May Affect Your Black Lung Benefits
(Form Number - CM-929; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Report of Changes That May Affect Your Black Lung Benefits
(Form Number - CM-929P; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Report of Earnings
(Form Number - LS-200; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Report of Injury Experience of Insurance Carrier or Self-Insured Employer
(Form Number - LS-274; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Report of Payments.
(Form Number - LS-513; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Report of Ventilatory Study
(Form Number - CM-2907; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Report on Selection of Delegates and Officers
(Form Number - LM-15A; Agency - Office of Labor-Management Standards)
Representative of Miners Designation Form
(Form Number - 2000-238; Agency - Mine Safety and Health Administration)
Representative Payee Report
(Form Number - CM-623; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Representative Payee Report
(Form Number - CM-623S; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Request an MSHA Individual Identification Number (MIIN)
(Form Number - 5000-46; Agency - Mine Safety and Health Administration)
Request for Appointment of Mediator
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Request for Earnings Information
(Form Number - LS-426; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Request for Examination and/or Treatment
(Form Number - LS-1; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Request for Intervention
(Form Number - LS-7; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Request To Be Selected As Payee
(Form Number - CM-910; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Roentgenographic Interpretation
(Form Number - CM-933; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Roentgenographic Quality Rereading
(Form Number - CM-933b; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Safety and Health Complaint
(Form Number - N/A; Agency - Occupational Safety and Health Administration)
Self Contained Self Rescuer (SCSR) Inventory and Report
(Form Number - 2000-222; Agency - Mine Safety and Health Administration)
Settlement Approval Request Section 8(i)
(Form Number - LS-8; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Settlement Judge Request
(Form Number - N/A; Agency - Office of Administrative Law Judges)
Statement of Recovery Letter with Long Form
(Form Number - CA-1108; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Statement of Recovery Letter with Short Form
(Form Number - CA-1122; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Stipulation Approval Request
(Form Number - LS-9; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Surety Company Annual Report
(Form Number - S-1; Agency - Office of Labor-Management Standards)
Survivor's Claim
(Form Number - EE-2; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
Survivor's Form For Benefits Under The Black Lung Benefits Act
(Form Number - CM-912; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
Terminal Trusteeship Report
(Form Number - LM-16; Agency - Office of Labor-Management Standards)
Time Analysis Form, used for claiming compensation, including repurchase of paid leave
(Form Number - CA-7a; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Trusteeship Report
(Form Number - LM-15; Agency - Office of Labor-Management Standards)
Uniform Billing Form
(Form Number - OWCP-04; Agency - Office of Workers' Compensation Programs)
Wage Complaints
(Form Number - N/A; Agency - Wage and Hour Division)
Wage Survey Interview Record
(Form Number - 232A; Agency - Employment and Training Administration)
Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives
(Form Number - LS-802; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers
(Form Number - LS-801; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
What A Federal Employee Should Do When Injured At Work
(Form Number - CA-10; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
(Form Number - OWCP-5b; Agency - Office of Workers' Compensation Programs)
en español
:
Evaluación de la capacidad de trabajo Condiciones cardiovasculares / pulmonares (Número de formulario - OWCP-5b; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
Work Capacity Evaluation for Musculoskeletal Conditions
(Form Number - OWCP-5c; Agency - Office of Workers' Compensation Programs)
en español
:
Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas (Número de formulario -  OWCP-5c; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
Work Capacity Evaluation Psychiatric/Psychological Conditions
(Form Number - OWCP-5a; Agency - Office of Workers' Compensation Programs)
en español
:
Evaluación de la capacidad de trabajo Condiciones psiquiátricas / psicológicas (Número de formulario - OWCP-5a; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
232
(Form Name - Domestic Agricultural In- Season Wage Report; Agency - Employment and Training Administration)
232A
(Form Name - Wage Survey Interview Record; Agency - Employment and Training Administration)
300, 300A, 301
(Form Name - Injury & Illness Recordkeeping Forms; Agency - Occupational Safety and Health Administration)
385
(Form Name - Domestic Agricultural In-season Wage Finding Process; Agency - Employment and Training Administration)
750A
(Form Name - Application for Alien Employment Certification - Part A; Agency - Employment and Training Administration)
750B
(Form Name - Application for Alien Employment Certification - Part B; Agency - Employment and Training Administration)
790
(Form Name - Agricultural and Food Processing Clearance Order; Agency - Employment and Training Administration)
2000-7
(Form Name - Legal Identification Report; Agency - Mine Safety and Health Administration)
2000-38
(Form Name - Electrically Operated Equipment Field Approval Application (Coal Only); Agency - Mine Safety and Health Administration)
2000-222
(Form Name - Self Contained Self Rescuer (SCSR) Inventory and Report; Agency - Mine Safety and Health Administration)
2000-224
(Form Name - Operator’s Annual Certification of Mine Rescue Teams Qualifications; Agency - Mine Safety and Health Administration)
2000-238
(Form Name - Representative of Miners Designation Form; Agency - Mine Safety and Health Administration)
4000-9
(Form Name - Record of Individual Exposure to Radon Daughters; Agency - Mine Safety and Health Administration)
5000-1
(Form Name - Certificate of Electrical/Noise Training; Agency - Mine Safety and Health Administration)
5000-3
(Form Name - Certificate of Physical Qualification for Mine Rescue Work; Agency - Mine Safety and Health Administration)
5000-23
(Form Name - Certificate of Training; Agency - Mine Safety and Health Administration)
5000-41
(Form Name - Health Activity Certification or Hoisting Engineers Qualification Request; Agency - Mine Safety and Health Administration)
5000-46
(Form Name - Request an MSHA Individual Identification Number (MIIN); Agency - Mine Safety and Health Administration)
5500
(Form Name - 5500 Series; Agency - Employee Benefits Security Administration)
7000-1
(Form Name - Mine Accident, Injury and Illness Report; Agency - Mine Safety and Health Administration)
7000-2
(Form Name - Quarterly Mine Employment and Coal Production Report; Agency - Mine Safety and Health Administration)
7000-51
(Form Name - Mine ID Request; Agency - Mine Safety and Health Administration)
7000-52
(Form Name - Contractor ID Request; Agency - Mine Safety and Health Administration)
8429
(Form Name - Complaint/Apparent Violation Form; Agency - Employment and Training Administration)
9033
(Form Name - Employers’ Attestation to Use Alien Crewmembers for Longshore Activities in U.S. Ports Form ETA 9033; Agency - Employment and Training Administration)
9033-A
(Form Name - Employers’ Attestation to Use Alien Crewmembers for Longshore Activities in the State of Alaska; Agency - Employment and Training Administration)
9035
(Form Name - LCA Online Application; Agency - Employment and Training Administration)
9089
(Form Name - Application for Permanent Employment Certification; Agency - Employment and Training Administration)
9127
(Form Name - Foreign Labor Certification Quarterly Activity Report; Agency - Employment and Training Administration)
9141
(Form Name - Application for Prevailing Wage Determination; Agency - Employment and Training Administration)
9141C
(Form Name - Application for Prevailing Wage Determination; Agency - Employment and Training Administration)
9142A
(Form Name - H-2A Application for Temporary Employment Certification; Agency - Employment and Training Administration)
9142B
(Form Name - H-2B Application for Temporary Employment Certification; Agency - Employment and Training Administration)
9142C
(Form Name - CW-1 Application for Temporary Employment Certification; Agency - Employment and Training Administration)
9165
(Form Name - Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage Determination Request Based on a Non-OES Survey; Agency - Employment and Training Administration)
AB-1
(Form Name - Appeal Form; Agency - Employees' Compensation Appeals Board)
CA-1
(Form Name - Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-2
(Form Name - Notice of Occupational Disease and Claim for Compensation; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-2a
(Form Name - Notice of Recurrence; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-5
(Form Name - Claim for Compensation by Widow, Widower, and/or Children; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-5b
(Form Name - Claim for Compensation by Parents, Brothers, Sisiters, GrandParents, or GrandChildren; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-6
(Form Name - Official Supervisor's Report of Employee's Death; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-7
(Form Name - Claim for Compensation; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-7a
(Form Name - Time Analysis Form, used for claiming compensation, including repurchase of paid leave; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-7b
(Form Name - Leave Buy Back (LBB) Worksheet/Certification and Election; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-10
(Form Name - What A Federal Employee Should Do When Injured At Work; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-12
(Form Name - Claim For Continuance of Compensation Under the Federal Employees' Compensation Act; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-17
(Form Name - Duty Status Report; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
en español
:
Informe de estado de servicio (Número de formulario - CA-17; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
CA-20
(Form Name - Attending Physician's Report; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
en español
:
Informe del médico tratante (Número de formulario - CA-20; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
CA-35
(Form Name - Evidence Required in Support of a Claim for Occupational Disease; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-40
(Form Name - Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-41
(Form Name - Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-42
(Form Name - Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-278
(Form Name - Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-721
(Form Name - Notice of Law Enforcement Officer's Injury Or Occupational Disease; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-722
(Form Name - Notice of Law Enforcement Officer's Death; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-1031
(Form Name - Letter to Dependants to Verify Claimant Support; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-1074
(Form Name - Letter to Parents in Death Claim Development; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-1108
(Form Name - Statement of Recovery Letter with Long Form; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-1122
(Form Name - Statement of Recovery Letter with Short Form; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CA-2231
(Form Name - Claim for Reimbursement Assisted Reemployment; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
CM-623
(Form Name - Representative Payee Report; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-787
(Form Name - Physician's/Medical Officer's Statement; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-893
(Form Name - Certificate of Medical Necessity; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-908
(Form Name - Notice of Termination, Suspension, Reduction or Increase in Benefit Payments; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-910
(Form Name - Request To Be Selected As Payee; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-911
(Form Name - Miner's Claim For Benefits Under The Black Lung Benefits Act; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-911a
(Form Name - Employment History; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-912
(Form Name - Survivor's Form For Benefits Under The Black Lung Benefits Act; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-913
(Form Name - Description Of Coal Mine Work and Other Employment; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-921
(Form Name - Instructions For Completion of Form CM-921; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-929
(Form Name - Report of Changes That May Affect Your Black Lung Benefits; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-929P
(Form Name - Report of Changes That May Affect Your Black Lung Benefits; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-933
(Form Name - Roentgenographic Interpretation; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-933b
(Form Name - Roentgenographic Quality Rereading; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-936
(Form Name - Authorization For Release Of Medical Information (Black Lung Benefits); Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-972
(Form Name - Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-981
(Form Name - Certification by School Official; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-988
(Form Name - Medical History and Examination for Coal Mine Workers' Pneumoconiosis; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-1159
(Form Name - Report of Arterial Blood Gas Study; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-2907
(Form Name - Report of Ventilatory Study; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-2970
(Form Name - Operator Response to Schedule for Submission of Additional Evidence; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-2970a
(Form Name - Operator Response to Notice of Claim; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
CM-623S
(Form Name - Representative Payee Report; Agency - Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation)
EE-1
(Form Name - Employee's Claim; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
EE-2
(Form Name - Survivor's Claim; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
EE-3
(Form Name - Employment History; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
EE-4
(Form Name - Employment History Affidavit; Agency - Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation)
LM-1
(Form Name - Labor Organization Information Report; Agency - Office of Labor-Management Standards)
LM-2
(Form Name - Labor Organization Annual Report; Agency - Office of Labor-Management Standards)
LM-3
(Form Name - Labor Organization Annual Report ; Agency - Office of Labor-Management Standards)
LM-4
(Form Name - Labor Organization Annual Report ; Agency - Office of Labor-Management Standards)
LM-10
(Form Name - Employer Report; Agency - Office of Labor-Management Standards)
LM-15
(Form Name - Trusteeship Report; Agency - Office of Labor-Management Standards)
LM-15A
(Form Name - Report on Selection of Delegates and Officers; Agency - Office of Labor-Management Standards)
LM-16
(Form Name - Terminal Trusteeship Report; Agency - Office of Labor-Management Standards)
LM-20
(Form Name - Agreement and Activities Report; Agency - Office of Labor-Management Standards)
LM-21
(Form Name - Receipts and Disbursements Report; Agency - Office of Labor-Management Standards)
LM-30
(Form Name - Labor Organization Officer and Employee Report; Agency - Office of Labor-Management Standards)
LS-1
(Form Name - Request for Examination and/or Treatment; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-4
(Form Name - Attorney Fee Approval Request; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-5
(Form Name - Application For Special Relief Fund; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-6
(Form Name - Commutation Application; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-7
(Form Name - Request for Intervention; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-8
(Form Name - Settlement Approval Request Section 8(i); Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-9
(Form Name - Stipulation Approval Request; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-18
(Form Name - Pre-Hearing Statement; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-33
(Form Name - Approval of Compromise of Third Person Cause of Action; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-200
(Form Name - Report of Earnings; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-201
(Form Name - Notice of Employee's Injury or Death; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-202
(Form Name - Employer's First Report of Injury or Occupational Illness; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-203
(Form Name - Employee's Claim for Compensation; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-204
(Form Name - Attending Physician's Supplementary Report; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-207
(Form Name - Notice of Controversion of Right to Compensation; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-208
(Form Name - Notice of Final Payment or Suspension of Compensation Payments; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-210
(Form Name - Employer's Supplementary Report of Accident or Occupational Illness; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-262
(Form Name - Claim for Death Benefits; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-265
(Form Name - Certification of Funeral Expenses; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-266
(Form Name - Application for Continuation of Death Benefit for Student; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-267
(Form Name - Claimant's Statement; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-271
(Form Name - Application for Self-Insurance instructions; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-272
(Form Name - Application to write Longshore Insurance (Carriers); Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-274
(Form Name - Report of Injury Experience of Insurance Carrier or Self-Insured Employer; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-275ic
(Form Name - Agreement and Undertaking (Insurance Carrier); Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-275si
(Form Name - Agreement and Undertaking (Self-Insured Employer); Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-276
(Form Name - Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-426
(Form Name - Request for Earnings Information; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-513
(Form Name - Report of Payments.; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-570
(Form Name - Carrier's Report of Issuance of Policy (formerly Card Report of Insurance); Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-801
(Form Name - Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
LS-802
(Form Name - Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives; Agency - Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation)
M-1
(Form Name - Multiple Employer Welfare Arrangements (MEWAs) Annual Report; Agency - Employee Benefits Security Administration)
N/A
(Form Name - Administrative Subpoena to Appear & Testify at a Deposition; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Administrative Subpoena to Appear & Testify at a Hearing; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Administrative Subpoena to Produce Documents, Information or Objects, or to Permit Inspection of Premises; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Agreement to Mediate; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Black Lung Benefits Act Evidence Summary Form; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Certificates of Achievement in Safety; Agency - Mine Safety and Health Administration)
N/A
(Form Name - Electronic Training Plan Advisor; Agency - Mine Safety and Health Administration)
N/A
(Form Name - Federal Contractor Discrimination Complaint; Agency - Office of Federal Contract Compliance Programs)
N/A
(Form Name - Hazardous Condition Complaint; Agency - Mine Safety and Health Administration)
N/A
(Form Name - Inspector General Hotline; Agency - Office of Inspector General)
N/A
(Form Name - LHWCA Prehearing Statement Form; Agency - Office of Administrative Law Judges)
N/A
(Form Name - LHWCA Uniform Stipulations Form; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Manage/Update Diesel Inventory; Agency - Mine Safety and Health Administration)
N/A
- (Form Name - Mechanical Power Presses Injury Form - Occupational Safety and Health Administration)
N/A
(Form Name - Report Commencement/Closure of Operation – Metal and Nonmetal Mines; Agency - Mine Safety and Health Administration)
N/A
(Form Name - Request for Appointment of Mediator; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Safety and Health Complaint; Agency - Occupational Safety and Health Administration)
N/A
(Form Name - Settlement Judge Request; Agency - Office of Administrative Law Judges)
N/A
(Form Name - Wage Complaints; Agency - Wage and Hour Division)
OWCP-01
(Form Name - Agreement and Undertaking (Self-Insured Employer; Agency - Office of Workers' Compensation Programs)
OWCP-04
(Form Name - Uniform Billing Form; Agency - Office of Workers' Compensation Programs)
OWCP-5a
(Form Name - Work Capacity Evaluation Psychiatric/Psychological Conditions; Agency - Office of Workers' Compensation Programs)
en español
:
Evaluación de la capacidad de trabajo Condiciones psiquiátricas / psicológicas (Número de formulario - OWCP-5a; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
OWCP-5b
(Form Name - Work Capacity Evaluation Cardiovascular/Pulmonary Conditions; Agency - Office of Workers' Compensation Programs)
en español
:
Evaluación de la capacidad de trabajo Condiciones cardiovasculares / pulmonares (Número de formulario - OWCP-5b; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
OWCP-5c
(Form Name - Work Capacity Evaluation for Musculoskeletal Conditions; Agency - Office of Workers' Compensation Programs)
en español
:
Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas (Número de formulario -  OWCP-5c; Agencia - Oficina de Programas de Compensación para Trabajadores - La División de Compensación para Trabajadores Federales, Estibadores y Portuarios)
OWCP-16
(Form Name - Rehabilitation Plan And Award; Agency - Office of Workers' Compensation Programs)
OWCP-17
(Form Name - Rehabilitation Maintenance Certificate; Agency - Office of Workers' Compensation Programs)
OWCP-20
(Form Name - Overpayment Recovery Questionnaire; Agency - Office of Workers' Compensation Programs)
OWCP-44
(Form Name - Rehabilitation Action Report; Agency - Office of Workers' Compensation Programs)
OWCP-915
(Form Name - Claim For Medical Reimbursement; Agency - Office of Workers' Compensation Programs)
OWCP-957A
– (Form Name - Medical Travel Refund Request – Mileage; Agency - Office of Workers' Compensation Programs)
OWCP-957B
– (Form Name - Medical Travel Refund Request – Expenses; Agency - Office of Workers' Compensation Programs)
OWCP-1168
(Form Name - Provider Enrollment form; Agency - Office of Workers' Compensation Programs)
OWCP-1500
(Form Name - Health Insurance Claim Form; Agency - Office of Workers' Compensation Programs)
S-1
(Form Name - Surety Company Annual Report; Agency - Office of Labor-Management Standards)
VETS-4212
(Form Name - Federal Contractor Reporting - Veteran Hiring; Agency - Veterans' Employment and Training Service)
WH-2
(Form Name - Application for Special Industrial Homeworker Certificate; Agency - Wage and Hour Division)
WH-4
(Form Name - H-1B Nonimmigrant Information; Agency - Wage and Hour Division)
WH-5
(Form Name - Certificate of Training Form; Agency - Wage and Hour Division)
WH-10
(Form Name - DBRA Report of Construction Contractor’s Wage Rates ; Agency - Wage and Hour Division)
WH-46
(Form Name - Application for Certificateto Employ Homeworkers; Agency - Wage and Hour Division)
WH-75
(Form Name - Homeworker Handbook ; Agency - Wage and Hour Division)
WH-75
(Form Name - Homeworker Handbook (Spanish); Agency - Wage and Hour Division)
WH-200
(Form Name - Application for Authority to Employ Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519; Agency - Wage and Hour Division)
WH-201
(Form Name - Higher Education to Employ its Full-time Students at Subminimum Wages Under Regulations 29 C.F.R. Part 519; Agency - Wage and Hour Division)
WH-202
(Form Name - Application for Authority to Employ Six or Fewer Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519; Agency - Wage and Hour Division)
WH-205
(Form Name - Application to Employ Student-Learners at Subminimum Wages; Agency - Wage and Hour Division)
WH-347
(Form Name - DBRA Certified Payroll Form; Agency - Wage and Hour Division)
WH-380-E
(Form Name - FMLA Certification of Health Care Providerfor Employee’s Serious Health Condition; Agency - Wage and Hour Division)
WH-380-F
(Form Name - FMLA Certification of Health Care Providerfor Family Member’s Serious Health Condition; Agency - Wage and Hour Division)
WH-381
(Form Name - FMLA Notice of Eligibility and Rights & Responsibilities; Agency - Wage and Hour Division)
WH-382
(Form Name - FMLA Designation Notice; Agency - Wage and Hour Division)
WH-384
(Form Name - FMLA Certification of Qualifying Exigency For Military Family Leave; Agency - Wage and Hour Division)
WH-385
(Form Name - FMLA Certification for Serious Injury orIllness of Covered Servicemember -- for Military Family Leave; Agency - Wage and Hour Division)
WH-385V
(Form Name - FMLA Certification for Serious Injury or Illness of a Veteran for Wage and Hour Division Military Caregiver Leave; Agency - Wage and Hour Division)
WH-501
(Form Name - MSPA Wage Statement; Agency - Wage and Hour Division)
WH-501
(Form Name - MSPA Wage Statement (Spanish); Agency - Wage and Hour Division)
WH-514
(Form Name - MSPA Vehicle Mechanical Inspection Report for Transportation Subjectto Department of Transportation Requirements ; Agency - Wage and Hour Division)
WH-515
(Form Name - MSPA Doctor’s Certificate; Agency - Wage and Hour Division)
WH-516
(Form Name - MSPA Worker Information – Terms of Employment ; Agency - Wage and Hour Division)
WH-516
(Form Name - MSPA Worker Information – Terms of Employment (Haitian Creole); Agency - Wage and Hour Division)
WH-516
(Form Name - MSPA Worker Information – Terms of Employment (Spanish); Agency - Wage and Hour Division)
WH-520
(Form Name - MSPA Housing Occupancy Certificate; Agency - Wage and Hour Division)
WH-521
(Form Name - MSPA Housing Terms and Conditions; Agency - Wage and Hour Division)
WH-530
(Form Name - MSPA Application for a Farm Labor Contractor or Farm Labor ContractorEmployee Certificate of Registration; Agency - Wage and Hour Division)
WH-530
(Form Name - MSPA Application for a Farm Labor Contractor or Farm Labor ContractorEmployee Certificate of Registration (Spanish); Agency - Wage and Hour Division)
WH-1481
(Form Name - EPPA Notice to Examinee; Agency - Wage and Hour Division)
Forms By Agency
5500
- 5500 Series
M-1
- Multiple Employer Welfare Arrangements (MEWAs) Annual Report
AB-1
- Appeal Form
232
- Domestic Agricultural In- Season Wage Report
232A
- Wage Survey Interview Record
385
- Domestic Agricultural In-season Wage Finding Process
750A
- Application for Alien Employment Certification - Part A
750B
- Application for Alien Employment Certification - Part B
790
- Agricultural and Food Processing Clearance Order
8429
- Complaint/Apparent Violation Form
9033
- Employers’ Attestation to Use Alien Crewmembers for Longshore Activities in U.S. Ports Form ETA 9033
9033-A
- Employers’ Attestation to Use Alien Crewmembers for Longshore Activities in the State of Alaska
9035
- LCA Online Application
9089
- Application for Permanent Employment Certification
9127
- Foreign Labor Certification Quarterly Activity Report
9141
- Application for Prevailing Wage Determination
9141C
- Application for Prevailing Wage Determination
9142A
- H-2A Application for Temporary Employment Certification
9142B
- H-2B Application for Temporary Employment Certification
9142C
- CW-1 Application for Temporary Employment Certification
9165
- Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage Determination Request Based on a Non-OES Survey
2000-7
- Legal Identification Report
2000-38
- Electrically Operated Equipment Field Approval Application (Coal Only)
2000-222
- Self Contained Self Rescuer (SCSR) Inventory and Report
2000-224
- Operator’s Annual Certification of Mine Rescue Teams Qualifications
2000-238
- Representative of Miners Designation Form
4000-9
- Record of Individual Exposure to Radon Daughters
5000-1
- Certificate of Electrical/Noise Training
5000-3
- Certificate of Physical Qualification for Mine Rescue Work
5000-23
- Certificate of Training
5000-41
- Health Activity Certification or Hoisting Engineers Qualification Request
5000-46
- Request an MSHA Individual Identification Number (MIIN)
7000-1
- Mine Accident, Injury and Illness Report
7000-2
- Quarterly Mine Employment and Coal Production Report
7000-51
- Mine ID Request
7000-52
- Contractor ID Request
N/A
- Certificates of Achievement in Safety
N/A
- Electronic Training Plan Advisor
N/A
- Hazardous Condition Complaint
N/A
- Manage/Update Diesel Inventory
N/A
- Report Commencement/Closure of Operation – Metal and Nonmetal Mines
N/A
- Mechanical Power Presses Injury Form
N/A
- Safety and Health Complaint
300, 300A, 301
- Injury & Illness Recordkeeping Forms
N/A
- Administrative Subpoena to Appear & Testify at a Deposition
N/A
- Administrative Subpoena to Appear & Testify at a Hearing
N/A
- Administrative Subpoena to Produce Documents, Information or Objects, or to Permit Inspection of Premises
N/A
- Agreement to Mediate
N/A
- Black Lung Benefits Act Evidence Summary Form
N/A
- LHWCA Prehearing Statement Form
N/A
- LHWCA Uniform Stipulations Form
N/A
- Request for Appointment of Mediator
N/A
- Settlement Judge Request
N/A
- Federal Contractor Discrimination Complaint
N/A
- Inspector General Hotline
LM-1
- Labor Organization Information Report
LM-2
- Labor Organization Annual Report
LM-3
- Labor Organization Annual Report
LM-4
- Labor Organization Annual Report
LM-10
- Employer Report
LM-15
- Trusteeship Report
LM-15A
- Report on Selection of Delegates and Officers
LM-16
- Terminal Trusteeship Report
LM-20
- Agreement and Activities Report
LM-21
- Receipts and Disbursements Report
LM-30
- Labor Organization Officer and Employee Report
S-1
- Surety Company Annual Report
OWCP-01
- Agreement and Undertaking (Self-Insured Employer)
OWCP-04
- Uniform Billing Form
OWCP-5a
- Work Capacity Evaluation Psychiatric/Psychological Conditions
en español
:
Evaluación de la capacidad de trabajo Condiciones psiquiátricas / psicológicas
OWCP-5b
- Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
en español
:
Evaluación de la capacidad de trabajo Condiciones cardiovasculares / pulmonares
OWCP-5c
- Work Capacity Evaluation for Musculoskeletal Conditions
en español
:
Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas
OWCP-16
- Rehabilitation Plan And Award
OWCP-17
- Rehabilitation Maintenance Certificate
OWCP-20
- Overpayment Recovery Questionnaire
OWCP-44
- Rehabilitation Action Report
OWCP-915
- Claim For Medical Reimbursement
OWCP-1168
- Provider Enrollment form
OWCP-1500
- Health Insurance Claim Form
CM-623
- Representative Payee Report
CM-787
- Physician's/Medical Officer's Statement
CM-893
- Certificate of Medical Necessity
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
- 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
CM-921
- Instructions For Completion of Form CM-921
CM-929
- Report of Changes That May Affect Your Black Lung Benefits
CM-929P
- Report of Changes That May Affect Your Black Lung Benefits
CM-933
- Roentgenographic Interpretation
CM-933b
- Roentgenographic Quality Rereading
CM-936
- Authorization For Release Of Medical Information (Black Lung Benefits)
CM-972
- Application for Approval of a Representative's Fee in a 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 Workers' Pneumoconiosis
CM-1159
- Report of Arterial Blood Gas Study
CM-2907
- Report of Ventilatory Study
CM-2970
- Operator Response to Schedule for Submission of Additional Evidence
CM-2970a
- Operator Response to Notice of Claim
CM-623S
- Representative Payee Report
EE-1
- Employee's Claim
EE-2
- Survivor's Claim
EE-3
- Employment History
EE-4
- Employment History Affidavit
CA-1
- Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
CA-2
- Notice of Occupational Disease and Claim for Compensation
CA-2a
- Notice of Recurrence
CA-5
- Claim for Compensation by Widow, Widower, and/or Children
CA-5b
- Claim for Compensation by Parents, Brothers, Sisiters, GrandParents, or GrandChildren
CA-6
- Official Supervisor's Report of Employee's Death
CA-7
- Claim for Compensation
CA-7a
- Time Analysis Form, used for claiming compensation, including repurchase of paid leave
CA-7b
- Leave Buy Back (LBB) Worksheet/Certification and Election
CA-10
- What A Federal Employee Should Do When Injured At Work
CA-12
- Claim For Continuance of Compensation Under the Federal Employees' Compensation Act
CA-17
- Duty Status Report
en español
:
Informe de estado de servicio
CA-20
- Attending Physician's Report
en español
:
Informe del médico tratante
CA-35
- Evidence Required in Support of a Claim for Occupational Disease
CA-40
- Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a
CA-41
- Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity
CA-42
- Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity
CA-278
- Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
CA-721
- Notice of Law Enforcement Officer's Injury Or Occupational Disease
CA-722
- Notice of Law Enforcement Officer's Death
CA-1031
- Letter to Dependants to Verify Claimant Support
CA-1074
- Letter to Parents in Death Claim Development
CA-1108
- Statement of Recovery Letter with Long Form
CA-1122
- Statement of Recovery Letter with Short Form
CA-2231
- Claim for Reimbursement Assisted Reemployment
LS-1
- Request for Examination and/or Treatment
LS-4
- Attorney Fee Approval Request
LS-5
- Application For Special Relief Fund
LS-6
- Commutation Application
LS-7
- Request for Intervention
LS-8
- Settlement Approval Request Section 8(i)
LS-9
- Stipulation Approval Request
LS-18
- Pre-Hearing Statement
LS-33
- Approval of Compromise of Third Person Cause of Action
LS-200
- Report of Earnings
LS-201
- Notice of Employee's Injury or Death
LS-202
- Employer's First Report of Injury or Occupational Illness
LS-203
- Employee's Claim for Compensation
LS-204
- Attending Physician's Supplementary Report
LS-207
- Notice of Controversion of Right to Compensation
LS-208
- Notice of Final Payment or Suspension of Compensation Payments
LS-210
- Employer's Supplementary Report of Accident or Occupational Illness
LS-262
- Claim for Death Benefits
LS-265
- Certification of Funeral Expenses
LS-266
- Application for Continuation of Death Benefit for Student
LS-267
- Claimant's Statement
LS-271
- Application for Self-Insurance instructions
LS-272
- Application to write Longshore Insurance (Carriers)
LS-274
- Report of Injury Experience of Insurance Carrier or Self-Insured Employer
LS-275ic
- Agreement and Undertaking (Insurance Carrier)
LS-275si
- Agreement and Undertaking (Self-Insured Employer)
LS-276
- Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart
LS-426
- Request for Earnings Information
LS-513
- Report of Payments.
LS-570
- Carrier's Report of Issuance of Policy (formerly Card Report of Insurance)
LS-801
- Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers
LS-802
- Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives
VETS-4212
- Federal Contractor Reporting - Veteran Hiring
N/A
- Wage Complaints
WH-2
- Application for Special Industrial Homeworker Certificate
WH-4
- H-1B Nonimmigrant Information
WH-5
- Certificate of Training Form
WH-10
- DBRA Report of Construction Contractor’s Wage Rates
WH-46
- Application for Certificateto Employ Homeworkers
WH-75
- Homeworker Handbook
WH-75
- Homeworker Handbook (Spanish)
WH-200
- Application for Authority to Employ Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519
WH-201
- Higher Education to Employ its Full-time Students at Subminimum Wages Under Regulations 29 C.F.R. Part 519
WH-202
- Application for Authority to Employ Six or Fewer Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519
WH-205
- Application to Employ Student-Learners at Subminimum Wages
WH-347
- DBRA Certified Payroll Form
WH-380-E
- FMLA Certification of Health Care Providerfor Employee’s Serious Health Condition
WH-380-F
- FMLA Certification of Health Care Providerfor Family Member’s Serious Health Condition
WH-381
- FMLA Notice of Eligibility and Rights & Responsibilities
WH-382
- FMLA Designation Notice
WH-384
- FMLA Certification of Qualifying Exigency For Military Family Leave
WH-385
- FMLA Certification for Serious Injury orIllness of Covered Servicemember -- for Military Family Leave
WH-385V
- FMLA Certification for Serious Injury or Illness of a Veteran for Wage and Hour Division Military Caregiver Leave
WH-501
- MSPA Wage Statement
WH-501
- MSPA Wage Statement (Spanish)
WH-514
- MSPA Vehicle Mechanical Inspection Report for Transportation Subjectto Department of Transportation Requirements
WH-515
- MSPA Doctor’s Certificate
WH-516
- MSPA Worker Information – Terms of Employment
WH-516
- MSPA Worker Information – Terms of Employment (Haitian Creole)
WH-516
- MSPA Worker Information – Terms of Employment (Spanish)
WH-520
- MSPA Housing Occupancy Certificate
WH-521
- MSPA Housing Terms and Conditions
WH-530
- MSPA Application for a Farm Labor Contractor or Farm Labor ContractorEmployee Certificate of Registration
WH-530
- MSPA Application for a Farm Labor Contractor or Farm Labor ContractorEmployee Certificate of Registration (Spanish)
WH-1481
- EPPA Notice to Examinee