ESA (EMPLOYMENT STANDARDS ADMINISTRATION) Forms in Word

EE 1 Form

Claim for Benefits under Energy Employees Occupational Illness Compensation Program Act

LS 1 Form

Request for Examination and/or Treatment

OWCP 1 Form

Agreement and Undertaking

WH 1 Form

Economic Survey Schedule

WD 10 Form

Report of Construction Contractor's Wage Rates

CA 1027 Form

Request for Employment Information

CA 1031 Form

CA- 1031- Form Letter Requesting More Information

CA 1032 Form

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

CA 1074 Form

Evidence Required in Support of Dependency Claim

CA 1087 Form

FECA Medical Report Forms, Claim for Compensation

CA 1090 Form

FECA Medical Report Forms, Claim for Compensation

CM 1093 Form

Affidavit of Deceased Miner's Condition

CA/EN 1108 Form

Statement of Recovery Forms

EB/EN 1108 Form

Statement of Recovery Forms

CA/EN 1122 Form

Statement of Recovery Forms

CM 1159 Form

Report of Arterial Gas Study

OWCP 1168 Form

Provider Enrollment Form

CA 12 Form

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

CA 1303 Form

FECA Medical Report Forms, Claim for Compensation

CA 1305 Form

FECA Medical Report Forms, Claim for Compensation

CA 1331 Form

FECA Medical Report Forms, Claim for Compensation

CA 1332 Form

FECA Medical Report Forms, Claim for Compensation

WH 14 Form

Application for Federal Certificate of Age

OWCP 1500 Form

Health Insurance Claim Form

CA 16 Form

FECA Medical Report Forms, Claim for Compensation

OWCP 16 Form

Rehabilitation Plan and Award

CA 17 Form

Duty Status Report

OWCP 17 Form

Rehabilitation Maintenance Certificate

LS 18 Form

Pre-Hearing Statement

EE 2 Form

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

WH 2 Form

Application for Special Industrial Homeworker's Certificate

CA 20 Form

Attending Physician Report

EE 20 Form

Energy Employee Occupational Illness Compensation Program Act Forms (various)

OWCP 20 Form

Overpayment Recovery Questionnaire

CM 200 Form

Maintenance of Receipt for Benefits Paid by a Coal Mine Operator

LS 200 Form

Report of Earnings

WH 200 Form

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 Form

Notice of Employee's Injury or Death

WH 201 Form

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 Form

Employer's First Report of Injury or Occupational Disease

WH 202 Form

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 Form

Employee's Claim for Compensation

LS 204 Form

Attending Physician's Supplementary Report

LS 205 Form

Physician's Report on Impairment of Vision

WH 205 Form

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

LS 206 Form

Payment of Compensation Without Award

LS 207 Form

Notice of Controversion of Right to Compensation

LS 208 Form

Notice of Final Payment or Suspension of Compensation Benefits

WH 209 Form

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

LS 210 Form

Employer's Supplementary Report of Accident or Occupational Illness

CA 2231 Form

Claim for Reimbursement-Assisted Reemployment

WH 226 Form

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

WH 226A A Form

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

LS 262 Form

Claim for Death Benefits

LS 265 Form

Certification of Funeral Expenses

LS 266 Form

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

LS 267 Form

Claimant's Statement

LS 271 Form

Application for Self-Insurance

LS 274 Form

Report of Injury Experience of Self-Insured Employer

CM 2907 Form

Report of Ventilator Study

CM 2970 Form

Operator Response to Schedule for Submission of Additional Evidence

CM 2970a A Form

Operator Response to   Response to Notice of Claim

CA 2a A Form

Notice of Recurrence

EE 3 Form

Employment History under the Energy Employees Occupational Illness Compensation Program Act

WH 3 ESPANOL Form

Employment Information Forms

WH 3 English Form

Employment Information Forms

WH 347 Form

Optional Use Payroll Form Under the Davis-Bacon Act

WH 380 Form

Certification of Health Care Provider

WH 381 Form

Employer Response to Employee Request for Family or Medical Leave

EE 4 Form

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

LS 426 Form

Request for Earnings Information

OWCP 44 Form

Rehabilitation Action Report

WH 46 Form

Application for Certificate to Employ Homeworkers

CA 5 Form

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

WH 501 ESPANOL Form

Wage Statement (Spanish)

WH 501 English Form

Wage Statement

LS 513 Form

Report of Payments

WH 514 English Form

Vehicle Mechanical Inspection Report for Transportation Subject to DOT Requirements

WH 514a ESPANOL Form

Vehicle Mechanical Inspection Report for Transportation Subject to DOL Safety Standards

WH 520 Form

Occupancy Certificate - Migrant and Seasonal Agricultural Worker   Protection Act

WH 521 Form

Housing Terms and Conditions

WH 530 Form

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

CA 5b B Form

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

CM 623 Form

Representative Payee Report

CM 623s S Form

Representative Payee Report

CA 7 Form

FECA Medical Report Forms, Claim for Compensation

EE 7 Form

Medical Requirements under the Energy Employees Occupational Illness Compensation Program Act

CA 721 Form

Notice of Law Enforcement Officer's Injury or Occupational Disease

CA 722 Form

Notice of Law Enforcement Officer's Death   

CM 787 Form

Physician's/Medical Officer's Report

CM 893 Form

Certificate of Medical Necessity

EE 9 Form

Energy Employee Occupational Illness Compensation Program Act   Forms (various)

CM 905 Form

Request for State or Federal Workers' Compensation Information

CM 907 Form

Report of Ventilator Study

CM 908 Form

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

CM 910 Form

Request to be Selected as Payee

CM 911 Form

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

CM 911a A Form

Employment History

CM 912 Form

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

CM 913 Form

Description of Coal Mine Work and Other Employment

CA 915 Form

Claimant for Medical Reimbursement

CM 915 Form

Miner Medical Reimbursement Form

CM 918 Form

Coal Mine Employment Affidavit

OWCP 92(UB-92) Form

Uniform Health Insurance Claim Form

CM 921 Form

Notice of Issuance of Insurance Policy

CM 929 Form

Report of Changes That May Affect Your Black Lung Benefits

CM 933 Form

Roentgenograhic Interpretation

CM 933b B Form

Roentgenographic Quality Rereading

CM 936 Form

Authorization for Release of Medical Information (Black Lung Benefits)

OWCP 957 Form

Medical Travel Refund Request

CM 970 Form

Operator Controversion

CM 970a A Form

Operator Response

CM 972 Form

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

CM 981 Form

Certification by School Official

CM 988 Form

Medical History and Examination for Coal Mine Worker's Pneumoconoisis

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