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U.S. Department of Labor Forms

Workers' Compensation Forms
Applicant Background Questionnaire [DOLRNO-1]
Application for Alien Employment Certification (Part A) [ETA 750A] (rev. 10/79)
Application for Alien Employment Certification (Part B) [ETA 750B] (rev. 10/79)
Application For Authority To Employ Workers With Disabilities At Special Minimum Wages [WH-226] (rev. 05/01)
Application For Continuation Of Death Benefit For Student [LS-266] (rev. 01/02)
Application For EFAST Electronic Signature And Codes For EFAST Transmitters And Signature Developers [EFAST-1] (rev. 12/00)
Application For Self-Insurance [LS-271] (rev. 05/03)
Approval Of Compromise Of Third Person Cause Of Action [LS-33] (rev. 09/74)
Attending Physician's Report [CA-20] (rev. 11/99)
Attending Physician's Supplemental Report [LS-204] (rev. 05/98)
Authorization For Release Of Medical Information (Black Lung Benefits) [CM-936] (rev. 12/99)
Certificate Of Electrical Training/Noise Training [MSHA 5000-1]
Certificate Of Physical Qualification For Mine Rescue Work [MSHA 5000-3] (07/96)
Certificate Of Training [MSHA 5000-23] (01/99)
Certification Of Funeral Expenses [LS-265] (rev. 05/02)
Certification Of Health Care Provider (Family And Medical Leave Act Of 1993) [WH-380] (rev. 12/99)
Claim For Compensation [CA-7] (rev. 11/99)
Claim For Compensation By Parents, Brothers, Sisters, Grandparents, Or Grandchildren [CA-5b] (rev. 01/97)
Claim For Compensation By Widow, Widower, And/Or Children [CA-5] (rev. 01/97)
Claim For Continuance Of Compensation Under The Federal Employees' Compensation Act [CA-12]
Claim For Death Benefits [LS-262] (rev. 09/98)
Claim For Reimbursement Assisted Reemployment [CA-2231] (rev. 07/01)
Claimant Medical Reimbursement Form [CA-915] (rev. 02/99)
Claimant's Statement [LS-267] (rev. 05/98)
Complaint Of Discrimination In Employment Under Federal Government Contracts [CC-4] (rev. 05/03)
Duty Status Report [CA-17] (rev. 01/97)
Electrically Operated Mining Equipment Field Approval Application (Coal Operator) [MSHA 2000-38] (rev. 06/84)
Eligibility Data Form: Uniformed Services Employment And Reemployment Rights Act And Veterans' Preference [VETS-1010] (rev. 02/99)
Employee's Claim For Compensation [LS-203] (rev. 09/98)
Employer Response To Employee Request For Family Or Medical Leave [WH-381] (rev. 06/97)
Employer's First Report Of Injury Or Occupational Illness [LS-202] (rev. 10/98)
Employer's Supplementary Report Of Accident Or Occupational Illness [LS-210] (rev. 10/98)
Evidence Required In Support Of A Claim For Occupational Disease [CA-35A] (rev. 08/88)
Federal Contractor Veterans' Employment Report [VETS-100]
Federal Employee's Notice Of Traumatic Injury Claim For Continuation Of Pay Compensation [CA-1] (rev. 04/99)
H-1B Nonimmigrant Information Form [ESA WH-4]
H-1C Nurses for Disadvantaged Areas [ETA 9081]
Health Activity Certification Or Hoisting Engineer Qualification Request Form [MSHA 5000-41]
Health Insurance Claim Form [HCFA-1500] (rev. 05/03)
Individual Characteristics Form. Work Opportunity Tax Credit And Welfare-To-Work Tax Credit [ETA 9061] (rev. 07/02)
Leave Buy Back (LBB) Worksheet/Certification And Election [CA-7B] (rev. 06/96)
Legal Identity Report [MSHA 2000-7] (rev. 02/02)
Log And Summary Of Occupational Injuries And Illnesses [OSHA 200]
Medical Certificate [WH-380] (rev. 12/99)
Medical Travel Refund Request [OWCP-957] (rev. 08/01)
Mine Accident, Injury And Illness Report [MSHA 7000-1] (rev. 02/00)
Notice Of Controversion Of Right To Compensation [LS-207] (rev. 06/97)
Notice Of Employee's Injury Or Death [LS-201] (rev. 01/99)
Notice Of Final Payment Or Suspension Of Compensation Payments [LS-208] (rev. 06/98)
Notice Of Law Enforcement Officer's Death [CA-722a] (rev. 10/01)
Notice Of Law Enforcement Officer's Injury Or Occupational Disease [CA-721a] (rev. 10/01)
Notice Of Occupational Disease And Claim For Compensation [CA-2] (rev. 01/97)
Notice Of Recurrence [CA-2a] (rev. 09/96)
Official Superior's Report Of Employee's Death [CA-6] (rev. 01/97)
Overpayment Recovery Questionnaire [OWCP-20] (rev. 06/02)
Payment Of Compensation Without Award [LS-206] (rev. 06/97)
Payroll [WH-347] (rev. 11/98)
Physician's Report On Impairment Of Vision [LS-205] (rev. 10/98)
Pre-Hearing Statement [LS-18] (rev. 06/97)
Quarterly Mine Employment And Coal Production Report [MSHA 7000-2] (rev. 07/97)
Record Of Individual Exposure To Radon Daughters [MSHA 4000-9] (rev. 01/79)
Recording And Reporting Occupational Injuries And Illnesses [OSHA 101] (rev. 02/81)
Rehabilitation Action Report [OWCP-44] (rev. 08/99)
Rehabilitation Maintenance Certificate [OWCP-17] (rev. 09/00)
Rehabilitation Plan And Award [OWCP-16] (rev. 05/95)
Report Of Earnings [LS-200] (rev. 05/98)
Report Of Injury Experience Of Self-Insured Employer [LS-274] (rev. 05/98)
Report Of Payments [LS-513] (rev. 05/98)
Report Of Termination Of Disability And/Or Payment [CA-3] (rev. 06/88)
Request For Examination And/Or Treatment [LS-1] (rev. 05/98)
Request For Family/Medical Leave (FMLA) [WH-381] (rev. 06/97)
Request For Wage Determination And Response To Request [SF-308] (rev. 05/85)
Request To Employee For Wage Earnings Information [LS-426] (rev. 05/98)
Supplemental Data Sheet For Application For Authority To Employ Workers With Disabilities At Special Minimum Wages [WH-226A] (rev. 05/01)
Time Analysis Form [CA-7A] (rev. 06/96)
Uniform Health Insurance Claim Form [UB-92]
Wage Statement (Optional Form) [WH-501] (rev. 06/98)
Wage Statement (Spanish) [WH-501S] (rev. 06/98)
Work Capacity Evaluation (Psychiatric/Psychological Conditions) [OWCP-5a] (rev. 10/01)
Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions) [OWCP-5b] (rev. 10/01)
Work Capacity Evaluation (Musculoskeletal Conditions) [OWCP-5c] (rev. 10/01)
Worker Information - Terms And Conditions Of Employment [WH-516] (rev. 05/96)
Worker Information - Terms And Conditions Of Employment (In Spanish) [WH-516] (rev. 05/96)


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