Energy Employees Occupational Illness Compensation Program Act Forms (Various)

ICR 200506-1215-001

OMB: 1215-0197

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1215-0197 200506-1215-001
Historical Active 200406-1215-007
DOL/ESA
Energy Employees Occupational Illness Compensation Program Act Forms (Various)
Revision of a currently approved collection   No
Regular
Approved without change 06/20/2005
Retrieve Notice of Action (NOA) 06/07/2005
  Inventory as of this Action Requested Previously Approved
08/31/2007 08/31/2007 08/31/2007
92,763 0 50,019
41,378 0 22,495
22,000 0 13,000

These forms are required to determine a claimant's eligibility for compensation under the EEOICPA, and are required to enable eligible claimants to receive benefits.

None
None


No

1
IC Title Form No. Form Name
Energy Employees Occupational Illness Compensation Program Act Forms (Various) EE-1, EE-2, EE-3, EE-4, EE-7, EE-8, EE-9, EE-10, EE-20

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 92,763 50,019 0 40,480 2,264 0
Annual Time Burden (Hours) 41,378 22,495 0 17,883 1,000 0
Annual Cost Burden (Dollars) 22,000 13,000 0 9,000 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/07/2005


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