EE-4 Spanish Employment History Affidavit for a Claim under the Energ

Medical Requirements under the Energy Employees

Occupational Illness Compensation Program Act

U.S. Department of Labor

Employment Standards Administration

Office of Workers’ Compensation Programs

OMB No. 1215-0197

Expiration Date: 08/31/2007

The information in this form is intended to notify a claimant or physician of the medical evidence needed to support all claims under

Part B or Part E of EEOICPA, and to establish a diagnosis of the following defined illnesses: Beryllium Sensitivity, Established Chronic

Beryllium Disease, Chronic Silicosis and Radiogenic Cancer. Medical evidence may include narrative reports, physician notes,

diagnostic test results, imaging studies, laboratory work-ups, pathology reports, operative reports, pulmonary function assessments,

autopsy evaluations, death certificates, etc. The completed medical package should be submitted to the appropriate district office of

OWCP. Decisions regarding coverage under EEOICPA are contingent on the submission of appropriate medical and factual evidence.

This form provides information regarding medical requirements only. Maintain a copy of all documents for your records.

General Requirements

All claims filed under EEOICPA must include a medical report(s) providing:

• A history of the claimed illness or death

• A physical examination and its findings

• The clinical laboratory tests performed and discussion of the results

• A diagnosis (ICD-9 coded, if possible) and the date when it was first documented

Requirements for a Diagnosis of Beryllium Sensitivity Under Part B Only

• Abnormal Beryllium Lymphocyte Proliferation Test (LPT) performed on blood or lung lavage cells

Requirements for a Diagnosis of Established Chronic Beryllium Disease Under Part B Only

If the initial date of diagnosis was made on or after January 1, 1993, medical documentation must include an Abnormal Beryllium

Lymphocyte Proliferation Test (LPT) and at least one (1) of the following:

• Lung biopsy showing a process consistent with chronic beryllium disease

• A computerized axial tomography scan showing changes consistent with chronic beryllium disease

• A pulmonary function study or exercise tolerance test showing pulmonary deficits consistent with chronic beryllium disease

If the initial date of diagnosis was made before January 1, 1993, medical documentation must include at least three (3) of the

following:

• Characteristic chest radiograph or computed tomography denoting abnormalities

• A restrictive or obstructive lung physiology test or diffusion lung capacity defect

• Lung pathology consistent with chronic beryllium disease

• A clinical course consistent with chronic respiratory disease disorder

• Immunologic tests showing beryllium sensitivity (skin patch test or beryllium test preferred)

Requirements for a Diagnosis of Chronic Silicosis Under Part B Only

One (1) of the following:

•

A chest radiograph, interpreted by a NIOSH-certified B reader, confirming the existence of pneumoconiosis with a 1/0 ILO

category or higher

• Results from a computer-assisted tomograph or other imaging technique consistent with silicosis

• A lung biopsy consistent with silicosis

Requirements for a Diagnosis of Radiogenic Cancer Under Part B or Part E

•

The pathology report(s) (e.g., tissue biopsy or blood test) that forms the basis for the diagnosis of cancer and identifies the

malignant neoplasm present

•

A narrative report that addresses whether there are metastases present and the affected anatomic sites, as well as the presence

of any cancer-related syndromes or other complications

Form EE-7

April 2005

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy

Employees Occupational Illness Compensation Program Act (42 U.S.C. 7384

et seq

.) (EEOICPA) is administered by the

Office of Workers’ Compensation Programs of the U.S. Department of Labor, which receives and maintains personal

information on claimants and their immediate families. (2) Information which the Office has received will be used to

determine eligibility for, and the amount of, benefits payable under the EEOICPA, and may be verified through

computer matches or other appropriate means. (3) Information may be given to the Federal agencies or private

entities that employed the claimant at the time of injury in order to verify statements made, answer questions

concerning the status of the claim, verify billing, and to consider other relevant matters. (4) Information may be

disclosed to physicians and other health care providers for use in providing treatment or medical rehabilitation, making

evaluations for the Office of Workers’ Compensation Programs and for other purposes related to the medical

management of the claim. (5) Information may be given to Federal, state, and local agencies for law enforcement

purposes, to obtain information relevant to a decision under the EEOICPA, to determine whether benefits are being

paid properly, including whether prohibited payments have been made, and, where appropriate, to pursue

salary/administrative offset and debt collection actions required or permitted by the Debt Collection Act. (6) Disclosure

of the claimant’s social security number (SSN) or tax identification number (TIN) is mandatory. The SSN or TIN, and

other information maintained by the Office, may be used for identification, to support debt collection efforts carried on

by the Federal government, and for other purposes required or authorized by law. (7) Failure to disclose all requested

information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average fifteen (15) minutes per response,

including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing

and reviewing the collection of information. If you have any comments regarding the burden estimate or any other

aspect of this collection of information, including suggestions for reducing this burden, send them to the Office of

Workers’ Compensation Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W.,

Washington, D.C. 20210. Do not submit the completed claim form to this address. Completed claims are to

be submitted to the appropriate district office of the Office of Workers’ Compensation Programs. Persons are not

required to respond to the information collections on this form unless it displays a currently valid OMB number.

Form EE-7

April 2005