Information Collection

Energy Employees Occupational Illness Compensation Program Act Forms (Various)

IC 13934 under ICR 200609-1215-013 · OMB 1215-0197.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0197 can be found here:

2007-06-14 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form EE-20 Energy Employees Occupational Illness Compensation Program Act Forms (Various) Form and Instruction
EE-7 Spanish Medical Requirements under the Energy Employees Occupati EE7-Spa1 (July 11, 2006).doc Form and Instruction
EE-1 Spanish Energy Employees Occupational Illness Compensation Progr EE1-Spa (June 11, 2006).doc Form and Instruction
EE-3 Spanish Employment History for a Claim Under the Energy Employee EE3-Spa (July 11, 2006).doc Form and Instruction
EE-4 Spanish Employment History Affidavit for a Claim under the Energ EE4-Spa.doc Form
EE-2 Spanish Claim for Survivor Benefits Under the Energy Employees O EE2-Spa (July 11, 2006).doc Form and Instruction
EE-1 English Claims for Benefits Under the Energy Employees Occupatio EE-1 (8-31-07).pdf www.dol.gov./esa/regs/compliance/owcp/eeoicp/clainsforms.htm Form and Instruction
EE-2 English Claim for Survivor Benefits Under the Energy Employees O EE-2 (8-31-07).pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm Form and Instruction
EE-3 English Employment History for a Claim Under the Energy Employee EE-3 (8-31-07).pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm Form and Instruction
EE-4 English Employment History Affidavit for a Claim Under the Energ EE-4 (8-31-07).pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm Form
EE-7 English Medical Requirements under the Energy Employees Occupati EE-7 (8-31-07).pdf Form
EE-8 Letter to Claimant Form EE-8 and EN-8 lung.EXP 8-31-07.doc Form
EE-9 Letter to Claimant Form EE-9 and EN-9 8-31-07.doc Form
EE-20 Letter to Claimant EN-20 (8-31-07).pdf Form and Instruction
EE-10 Claim for Additional Wage-Loss and/or Impairment Under t EE-10 8-31-07.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Energy Employees Occupational Illness Compensation Program Act Forms (Various)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 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

Information Collection Instruments:

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

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90,863	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	92,763	92,763
Annual IC Time Burden (Hours)	41,378	41,378
Annual IC Cost Burden (Dollars)	22,000	22,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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