OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

EEOICP Forms for Individuals or Households

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

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

View Information Collection (IC)

EEOICP Forms for Individuals or Households
 
No Modified
 
Required to Obtain or Retain Benefits
 
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

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

Income Security General Retirement and Disability

DOL/ESA 49  67 FR 16891

58,349 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 58,349 0 4,000 -38,414 0 92,763
Annual IC Time Burden (Hours) 29,340 0 1,333 -13,371 0 41,378
Annual IC Cost Burden (Dollars) 4,629 0 0 -17,371 0 22,000

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.