Energy Employees Occupational Illness Compensation Program Act Forms (Various)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EE-7 Spanish Department of Energy's Response to Employment History for Claim Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	New	Available
Form EE-7 Department of Energy's Response to Employment History for Claim Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	New	Available
Form EE-1 English Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-20 Letter to Claimant	Form and Instruction	Modified	Available
Form EE-2 English Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-4 Spanish Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-2 Spanish Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-3 English Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-3 Spanish Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-1 Spanish Energy Employees Occupational Illness Compensation Program Act Forms. (Various)	Form and Instruction	Modified	Available
Form EE-4 English Employment History Affidavit for a Claim Under the Energy Employees Occupational Ilness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-9 Letter to Claimant	Form	Modified	Available
Form EE-8 Letter to Claimant	Form	Modified	Available
Form EE-10 Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act	Form and Instruction	Modified	Available
SS for revision to 1215-0197 (2007 clearance).pdf	Supporting Statement A	Uploaded 2007-06-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
178684	EEOICP Forms for Federal Government	Other-Letter	New
178683	EEOICP Forms for Business or other for profits	Form and Instruction	New	Department of Energy's Response to Employment History for Claim Under the Energy Employees Occupational Illness Compensation Program Act
178683	EEOICP Forms for Business or other for profits	Form and Instruction	New	Department of Energy's Response to Employment History for Claim Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Other-Letter	Modified
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Energy Employees Occupational Illness Compensation Program Act Forms. (Various)
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History Affidavit for a Claim Under the Energy Employees Occupational Ilness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act

ICR Details

OMB Control No: 1240-0002	ICR Reference No: 201003-1240-002
Status: Historical Active	Previous ICR Reference No: 200609-1215-013
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Energy Employees Occupational Illness Compensation Program Act Forms (Various)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/12/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/12/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved
Responses	79,062	0	92,763
Time Burden (Hours)	35,447	0	41,378
Cost Burden (Dollars)	4,629	0	22,000

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Abstract: The EE forms are required to determine a claimant's eligibility for compensation under the EEOICPA and are required to enable eligible claimants to receive benefits.

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Authorizing Statute(s): US Code: 42 USC 7385(s) through 11 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 9976	03/06/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 32866	06/14/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
EEOICP Forms for Business or other for profits	EE-7, EE-7 Spanish	Department of Energy's Response to Employment History for Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Department of Energy's Response to Employment History for Claim Under the Energy Employees Occupational Illness Compensation Program Act
EEOICP Forms for Federal Government
EEOICP Forms for Individuals or Households	EE-2 English, EE-3 English, EE-4 English, EE-8, EE-9, EE-10, EE-20, EE-2 Spanish, EE-1 Spanish, EE-3 Spanish, EE-4 Spanish, EE-1 English	Letter to Claimant ,   Letter to Claimant ,   Employment History Affidavit for a Claim Under the Energy Employees Occupational Ilness Compensation Program Act ,   Energy Employees Occupational Illness Compensation Program Act Forms. (Various) ,   Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant ,   Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act

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ICR Summary of Burden

table that charts list of burden

	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	79,062	92,763	0	4,051	-17,752	0
Annual Time Burden (Hours)	35,447	41,378	0	2,149	-8,080	0
Annual Cost Burden (Dollars)	4,629	22,000	0	0	-17,371	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: OMB directives required that EEOICPA implement two additions to this ICR which required two new forms EE-12 and EE-13 which is a program change of +2,149 burden hours. There has also been an overall adjustment of -8,080 in burden hours due to a decrease in the number of claimants. There has also been a decrease in the operation and maintenance cost since mail outs are only for the EE-1 and EE-2 which is a decrease from $22,000 to $4,629.

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Annual Cost to Federal Government: $396,504

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/14/2007

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