Energy Employees Occupational Illness Compensation Program Act Forms (Various)

Energy Employees Occupational Illness Compensation Program Act Forms (Various)

OMB: 1215-0197

IC ID: 13934

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form
Form
Form
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Energy Employees Occupational Illness Compensation Program Act Forms (Various)
 
No Modified
 
Voluntary
 
20 CFR 30.101 20 CFR 30.103 20 CFR 30.111-114 20 CFR 30.206-207 20 CFR 30.212-215 20 CFR 30.221-222 20 CFR 30.415-417 20 CFR 30.100 20 CFR 30.505 20 CFR 30.620

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction EE-20 Letter to Claimant EN-20 (8-31-07).pdf Yes Yes Fillable Fileable Signable
Form and Instruction EE-1 English Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act EE-1 (8-31-07).pdf http://www.dol.gov./esa/regs/compliance/owcp/eeoicp/clainsforms.htm Yes Yes Fillable Fileable Signable
Form EE-7 English Medical Requirements under the Energy Employees Occupational Illness Compensation Program ACt EE-7 (8-31-07).pdf No   Paper Only
Form and Instruction EE-10 Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act EE-10 8-31-07.pdf No   Paper Only
Form and Instruction EE-1 Spanish Energy Employees Occupational Illness Compensation Program Act Forms. (Various) EE1-Spa (June 11, 2006).doc Yes Yes Fillable Fileable Signable
Form and Instruction EE-3 Spanish Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act EE3-Spa (July 11, 2006).doc Yes Yes Fillable Fileable Signable
Form and Instruction EE-3 English Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act EE-3 (8-31-07).pdf http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm Yes Yes Fillable Fileable Signable
Form and Instruction EE-2 Spanish Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act EE2-Spa (July 11, 2006).doc Yes Yes Fillable Fileable Signable
Form and Instruction EE-7 Spanish Medical Requirements under the Energy Employees Occupational Illness Compensation Act EE7-Spa1 (July 11, 2006).doc No   Paper Only
Form EE-4 Spanish Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act EE4-Spa.doc Yes Yes Fillable Fileable Signable
Form and Instruction EE-2 English Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act EE-2 (8-31-07).pdf http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm Yes Yes Fillable Fileable Signable
Form EE-8 Letter to Claimant Form EE-8 and EN-8 lung.EXP 8-31-07.doc No   Paper Only
Form EE-9 Letter to Claimant Form EE-9 and EN-9 8-31-07.doc No   Paper Only
Form EE-4 English Employment History Affidavit for a Claim Under the Energy Employees Occupational Ilness Compensation Program Act EE-4 (8-31-07).pdf http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm Yes Yes Fillable Fileable Signable


 

90,863 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 92,763 0 0 0 0 92,763
Annual IC Time Burden (Hours) 41,378 0 0 0 0 41,378
Annual IC Cost Burden (Dollars) 22,000 0 0 0 0 22,000

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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