Information Collection

EEOICP Forms for Individuals or Households

IC 13934 under ICR 200702-1215-010 · OMB 1215-0197.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EE-8 EEOICP Forms for Individuals or Households	Form
EE-12 and EN-12 (draft) (2007 clearance).doc	Other-Letter
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-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 and Instruction
EE-1 Spanish Energy Employees Occupational Illness Compensation Progr EE1-Spa (June 11, 2006).doc www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm	Form and Instruction
EE-3 Spanish Employment History for a Claim Under the Energy Employee EE3-Spa (July 11, 2006).doc 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-2 Spanish Claim for Survivor Benefits Under the Energy Employees O EE2-Spa (July 11, 2006).doc www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm	Form and Instruction
EE-4 Spanish Employment History Affidavit for a Claim under the Energ EE4-Spa.doc www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.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-20 Letter to Claimant EN-20 (8-31-07).pdf	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-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:

EEOICP Forms for Individuals or Households

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.101 20 CFR 30.103 20 CFR 30.102 20 CFR 30.111 20 CFR 30.221 20 CFR 30.113 20 CFR 30.100 20 CFR 30.114 20 CFR 30.206 20 CFR 30.207 20 CFR 30.212 20 CFR 30.213 20 CFR 30.214 20 CFR 30.222 20 CFR 30.231 20 CFR 30.415 20 CFR 30.416 20 CFR 30.417 20 CFR 30.505 20 CFR 30.620 20 CFR 30.806

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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 and Instruction	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
Form and Instruction	EE-1 Spanish	Energy Employees Occupational Illness Compensation Program Act Forms. (Various)	EE1-Spa (June 11, 2006).doc	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm	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	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm	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	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-4 Spanish	Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act	EE4-Spa.doc	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm	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 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 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
Other-Letter			EE-12 and EN-12 (draft) (2007 clearance).doc		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/ESA 49

FR Citation: 67 FR 16891

Number of Respondents: 58,349

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	58,349	4,000	-38,414	92,763
Annual IC Time Burden (Hours)	29,340	1,333	-13,371	41,378
Annual IC Cost Burden (Dollars)	4,629	0	-17,371	22,000

Documents for IC

table that charts IC Documents
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.