Energy Employees Occupational Illness Compensation Program Act Forms

OMB 1240-0002

Address change for the EE-1, EE-1-SPA EE-2-SPA, EE-2, EE/EN-8, EE/EN-9, EE/EN-10, EE/EN-11A EE/EN-11B, EE/EN-12, EE/EN-16, EE-17A and EE-17B only. The Energy Employee forms are required to determine a claimant's eligibility for compensation under the Energy Employee Occupation Illness Compensation Program Act and are required to enable eligible claimants to receive benefits.

The latest form for Energy Employees Occupational Illness Compensation Program Act Forms expires 2022-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form EE-13 with EN-13 EEOICP Forms for State Governments Form
Form EE-7-Spa EEOICP Forms for Private Sector Form
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction
1240-0002 Supporting Statement 2.22.22.docx Supporting Statement A
1240-0002 Supporting regulatory and statutory provisions.docx Supplementary Document
Form EE-5.pdf Supplementary Document
Supporting Regulations.pdf Supplementary Document
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)
EE -5B - Supplemental Employment Evidence - DOE Contractors
EE 5A - Supplemental Employment Evidence
EEOICP Forms for State Governments Form
EEOICP Forms for Private Sector Form
EEOICP Forms for Individuals or Households Form and Instruction

All Historical Document Collections

202109-1240-002 Approved with change	Extension without change of a currently approved collection	2022-03-01
202008-1240-064 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-20
202004-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-04-12
202002-1240-019 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-02-25
201901-1240-001 Approved without change	Revision of a currently approved collection	2019-02-09
201610-1240-003 Approved without change	Revision of a currently approved collection	2016-12-30
201510-1240-002 Comment filed on proposed rule and continue	Revision of a currently approved collection	2015-11-18
201304-1240-001 Approved without change	Revision of a currently approved collection	2013-10-29
201004-1240-002 Approved without change	Revision of a currently approved collection	2010-08-09
201003-1240-002 Approved without change	Revision of a currently approved collection	2010-03-12

OMB Details

EEOICP Forms for Individuals or Households

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form EE-20 and EN-20	Letter to Claimant	Paper Only	Form and instruction
Form EE-17A	CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT	Fillable Fileable Signable	Form and instruction
Form EE-17B	PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION	Fillable Fileable Signable	Form and instruction
Form EE-16 and EN-16	Letter to Claimant	Paper Only	Form
Form EE-12 and EN-12	Letter to Claimant	Paper Only	Form
Form EE-11B and EN-11B	Letter to Claimant	Paper Only	Form
Form EE-11A and EN-11A	Letter to Claimant	Paper Only	Form
Form Form EE-8 and EN-8	Letter to Claimant	Paper Only	Form
Form EE-9 and EN-9	Letter to Claimant	Paper Only	Form
Form EE-4 English	Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and instruction
Form EE-2 English	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and instruction
Form EE-1 English	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and instruction
Form EE-3 Spanish	Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia	www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and instruction
Form EE-3 English	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and instruction
Form EE-1 Spanish	Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia	www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Form and instruction
Form EE-2 Spanish	Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia	www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Form and instruction
Form EE_10 and EN-10	Letter to Claimant	Paper Only	Form
Form EE-4 Spanish	Declaracion jurada sobre historial de empleo para reclamacion sequin la Ley del Programa de Indemnizacioon por Enfermedades Ocupacionales para Empleados del Sector de la Energia	www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.