SS for revision to 1215-0197 (2007 clearance)

SUPPORTING STATEMENT
ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT
FORMS (VARIOUS)
OMB NO. 1215-0197
1.
The Office of Workers’ Compensation Programs (OWCP) is the
primary agency responsible for the administration of the Energy
Employees Occupational Illness Compensation Program Act of 2000,
as amended (EEOICPA or Act), 42 U.S.C. § 7384 et seq. The Act
provides for timely payment of compensation to covered employees
and, where applicable, survivors of such employees, who sustained
either “occupational illnesses” or “covered illnesses” incurred
in the performance of duty for the Department of Energy and
certain of its contractors and subcontractors. The Act sets
forth eligibility criteria for claimants for compensation under
Part B and Part E of the Act, and outlines the various elements
of compensation payable from the Fund established by the Act.
The following sections of the regulations implementing the Act
contain currently approved information collection requirements in
OMB Control No. 1215-0197: 20 CFR 30.100, 30.101, 30.102,
30.103, 30.111, 30.112, 30.113, 30.114, 30.206, 30.207, 30.212,
30.213, 30.214, 30.215, 30.221, 30.222, 30.226, 30.231, 30.232,
30.415, 30.416, 30.417, 30.505, 30.620, 30.806, 30.905 and
30.907. This ICR seeks to revise No. 1215-0197 by adding two new
information collection requirements. One new requirement is
found in § 7385s-11 of the Act, and will be implemented with the
new Form EE-13. The other new information collection requirement
(Form EE-12) will be implemented using the existing requirements
in No. 1215-0197.
The information collections in this ICR collect demographic,
factual and medical information needed to determine entitlement
to benefits under the EEOICPA. Before benefits may be paid, the
case file must contain medical and employment evidence showing
the claimant’s eligibility. The various collections in this ICR
and the purpose of each are listed below:
EE-1 -- Used to file a claim under Part B and/or E of EEOICPA,
and is to be completed by the living current or former employee.
It requests information about the illness or illnesses being
claimed, and information about tort suits, settlements or awards
in litigation, state workers’ compensation benefits, and fraud
convictions that impact entitlement. Also available in Spanish.
(20 CFR 30.100, 30.103, 30.505 and 30.620)
EE-2 –- Used by the survivor
claim under Parts B and/or E
on both the survivor and the
information about illnesses,

of a deceased employee to file a
of EEOICPA. It requests information
deceased employee. It also requests
tort suits, settlements or awards in
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litigation, state workers’ compensation benefits, and fraud
convictions that impact entitlement. Also available in Spanish.
(20 CFR 30.101, 30.103, 30.505 and 30.620)
EE-3 -- Used to gather factual information about the employee’s
work history. Also available in Spanish. (20 CFR 30.103, 30.111,
30.113, 30.114, 30.206, 30.212, 30.214, 30.221 and 30.231)
EE-4 –- Used to support the claimed employment history (supplied
by the employee or survivor) by affidavit. Also available in
Spanish. (20 CFR 30.103, 30.111, 30.113, 30.114, 30.206, 30.212,
30.214, 30.221 and 30.231)
EE-5A -- Used to collect supplemental employment evidence from
claimants to substantiate periods of unverified employment.
There is no standard form or format for the submission of this
information. For purposes of identification only, this
requirement has been designated the “EE-5A.” (20 CFR 30.112)
EE-5B – Used to collect information from current and former
contractors of DOE to substantiate periods of unverified
employment. There is no standard form or format for the
submission of the information. This requirement is currently
approved in OMB Control No. 1215-0199. For purposes of
identification only, this requirement has been designated the
“EE-5B.” (20 CFR 30.106)
EE-7 –- Informs an employee, survivor or physician of the medical
evidence needed to establish a diagnosis of an “occupational
illness” under Part B or a “covered illness” under Part E of
EEOICPA. Also available in Spanish. (20 CFR 30.103, 30.207,
30.215, 30.222, 30.232(a) and (b), 30.415, 30.416 and 30.417)
EE-7A -- Required when an injury, illness, or disability is
sustained as a consequence of an “occupational illness” under
Part B or a “covered illness” under Part E of EEOICPA. There is
no standard form or format for the submission of this medical
information. For purposes of identification only, this
requirement has been designated the “EE-7A.” (20 CFR 30.207,
30.215, 30.222, 30.226 and 30.232(c))
EE-7B -- Required to support a claim from a covered Part E
employee for permanent impairment due to an accepted “covered
illness” under Part E. There is no standard form or format for
the submission of this medical information. For purposes of
identification only, this requirement has been designated the
“EE-7B.” (20 CFR 30.905 and 30.907)
EE-8 -- Letter to claimant, sent with enclosure EN-8, used to
obtain information on the employee’s smoking history when lung
cancer due to radiation is claimed. Guidelines issued by HHS
require OWCP to ask for information regarding the employee’s
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smoking history before OWCP can determine the probability of
causation for radiogenic lung cancer. (20 CFR 30.213)
EE-9 -- Letter to claimant, sent with enclosure EN-9, used to
obtain information concerning the race or ethnicity of the
employee when radiogenic skin cancer is claimed. Guidelines
issued by HHS require OWCP to ask for this particular information
regarding the employee’s race/ethnicity before OWCP can determine
the probability of causation for radiogenic skin cancer. (20 CFR
30.213)
EE-10 –- Used by a covered Part E employee who has received an
award for wage-loss and/or impairment due to a “covered illness”
to claim for a subsequent calendar year of wage-loss and/or any
additional impairment. It requests information needed to support
a claim for an additional award. (20 CFR 30.102, 30.103, 30.505)
EE-10A -- Used to collect alternative evidence of wages from a
covered Part E employee for an initial claim for wage-loss due to
an accepted “covered illness” under Part E. There is no standard
form or format for the submission of this wage information. For
purposes of identification only, this requirement has been
designated the “EE-10A.” (20 CFR 30.806)
EE-12 -- Letter to covered Part B and E employees receiving
medical benefits, sent with enclosure EN-12, used to collect
updated information about settlements or awards in litigation and
state workers’ compensation benefits that impact continuing
entitlement. (20 CFR 30.100 and 30.505)
EE-13 – Letter to state workers’ compensation authorities, sent
with enclosure EN-13, used to identify covered Part E employees
receiving medical benefits who have also been award state
workers’ compensation for their covered illnesses. (42 USC 7385s11)
EE-20 -- Letter to claimant, sent with enclosure EN-20, used to
obtain financial information necessary to pay approved claims
under Part B or Part E of EEOICPA. (20 CFR 30.505 and 30.620)
In addition to the above reporting requirements, the Form EE-5 is
sent to the Department of Energy (DOE) and is used to verify the
alleged employment history submitted by the claimant. The EE-5
is a verification document only. The DOE reviews employment
information in its files to verify the information. This form is
not a public use form and no burden has been assigned. A copy of
the form is included in this ICR for informational purposes only.
2. The information collected by these forms is used by claims
examiners in OWCP to determine eligibility for compensation. The
information, with the medical evidence and other supporting
documentation, is used to determine whether or not the claimant
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is entitled to compensation under Part B and/or E of EEOICPA.
3.
In accordance with the Government Paperwork Elimination Act,
the current Forms EE-1, EE-2, EE-3 and EE-4 (both English and
Spanish versions) are electronically interactive and are posted
on the Internet at http://www.dol.gov/esa/regs/compliance/owcp/
eeoicp/claimsforms.htm. A claimant may complete the form online
and submit a digitally signed version, or print out a paper copy
and mail it to OWCP. Once the revision to No. 1215-0197 is
approved, the currently posted versions of these forms will be
replaced with revised versions.
The EE-5A, EE-5B, EE-7, EE-7A, EE-7B and EE-10A are non-form
collection requirements and do not have “form” to be posted on
the Internet. The EE-5 isn’t a form subject to GPEA, and the EE20 requires an original signature for audit purposes, so they are
also not posted on the Internet. Forms EE-10 and EE-12 is sent
to only approved claimants at a particular time and at a
particular stage in the claims adjudication process, so it is
impractical for OWCP to make this form electronically interactive
since doing so would likely lead to its use by respondents who
have no legal basis to claim for the benefits claimed with the
EE-10. The EE-13 is sent to state workers’ compensation
authorities and is accompanied by Privacy Act information;
therefore it is impractical for OWCP to make this form
electronically interactive. And finally, the EE-8 and EE-9 are
claims development letters, generated by claims examiners, and
are contained in OWCP’s word processing software.
4. The information requested in these collections is not
duplicative of any information available elsewhere. The
claimants, their survivors, their employers, others knowledgeable
about their employment, their physicians and state workers’
compensation authorities are the only sources of the required
information.
5. The information collections have been streamlined to obtain
the necessary information while imposing the minimum burden on
the respondent. They impose a burden on individuals, rather than
small businesses or other small entities. The EE-7, EE-7A and
EE-7B do not impose any additional burden on small businesses or
other small entities since providing medical evidence is part of
medical providers’ usual business practices. The information
collections in No. 1215-0197 do not have a significant economic
impact on a substantial number of small businesses.
6. If this information were not collected, or were collected
less frequently, OWCP would be unable to properly provide
compensation to EEOICPA claimants. If compensation were paid in
the absence of full information, there would be numerous
incorrect payments.
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7. There are no special circumstances for the collection of this
information.
8. Comments concerning the information collection requirements
being added to No. 1215-0197 in this revision were solicited in a
Federal Register notice published on ********, 2007. No comments
were received.
9. No payment or gift is provided to a respondent, other than
compensation payments.
10. The information collected by No. 1215-0197 is protected under
the Privacy Act in the system of records known as DOL/ESA-49.
11. There are no questions of a sensitive nature contained in No.
1215-0197.
12. The chart below shows the projected burden hours based on a
total estimated number of claims filed annually of 21,042.
Burden hour estimates have been derived from actual respondent
usage of these forms for FY2006.
Require- Time To
ment
Complete
EE-1
EE-2
EE-3
EE-4
EE-5A
EE-5B
EE-7
EE-7A
EE-7B
EE-8
EE-9
EE-10
EE-10A
EE-12
EE-13
EE/EN-20
TOTALS

17
21
60
30
30
30
15
15
15
5
5
5
30
20
16
5

min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
hrs.
min.

Freq.
of Resp.
1
1
1
1
1
20
1
1
1
1
1
1
1
1
1
1

Number of
Respondents

Number of
Responses

Hours
Burden

6,711
14,331
16,748
4,187
2,884
25
16,748
2,311
1,103
968
826
100
37
4,000
51
7,557

6,711
14,331
16,748
4,187
2,884
500
16,748
2,311
1,103
968
826
100
37
4,000
51
7,557

1,899
2,349
1,675
2,094
1,442
250
4,187
578
276
81
69
8
19
1,320
48,960
6,295

78,587

79,062

71,502

The requirements have a total respondent burden hour estimate of
71,502. Using the current national average hourly earnings of
$16.22 from the Bureau of Labor Statistics, the respondent cost
estimate for these requirements is $1,159,762 (71,502 x $16.22 =
$1,159,762).

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13. There are no recordkeeping or collection costs associated
with the factual information collected on the EE-1, EE-2, EE-3,
EE-4, EE-5A, EE-5B, EE-8, EE-9, EE-10, EE-10A, EE-12 or EE-20.
Since the medical and factual information requested by the EE-7,
EE-7A, EE-7B and EE-13 is kept as a usual and customary business
practice, there is no additional recordkeeping or collection cost
associated with those requirements. We anticipate that the
medical examination requirement for a consequential injury
represented by the EE-7A will continue to almost always result in
a finding by OWCP that the consequential injury is compensable.
We also anticipate that the impairment evaluation requirements
represented by the EE-7B will, in nearly all cases, meet the
criteria needed for payment set out in the regulations. For
these reasons, we have added no operation and maintenance costs
for these requirements. The only operation and maintenance cost
in No. 1215-0197 is for mailing. An estimated 50 percent of the
EE-1 and EE-2 forms will involve mailing costs; the remainder
will be completed and submitted with no mailing costs at a DOL
resource center. The EE-3 form always accompanies the EE-1 or
EE-2, therefore not requiring separate mailing. An estimated
annual total of 51,793 mailed responses at $.39 + $.03 (postage +
envelope) per response = $21,753.
14. Federal Cost Estimate:
Review Costs:
Requirement

Time
Total
to Review Responses

Reviewer
(GS-11/4
Hourly*)

EE-1
EE-2
EE-3
EE-4
EE-5A
EE-5B
EE-7
EE-7A
EE-7B
EE-8
EE-9
EE-10
EE-10A
EE-12
EE-13
EE/EN-20

5
5
15
15
10
10
15
15
15
3
3
5
10
5
8
5

$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89
$27.89

min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
min.
hrs.
min.

6,711
14,331
16,748
4,187
2,884
500
16,748
2,311
1,103
968
826
100
37
4,000
51
7,557

*Using Salary Table 2006-RUS
Total number of responses (annually)..79,062
Total time to review..................13,970 Hours
Total Review Cost.....................$396,254
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Cost
$15,591.24
$33,294.31
$116,775.43
$29,193.86
$13,673.91
$2,370.65
$116,775.43
$16,113.45
$ 7,690.67
$1,349.88
$1,151.86
$2,323.24
$1,754,28
$9,259.48
$11,379.12
$17,556.70

Printing..............................$1,000
Mailing (forms are submitted to the
Federal government; there is potential
Federal postage cost for EE-20).......$3,174
Total Federal Cost....................$400,428
15. Since the addition of the new requirements implemented using
the new EE-12 and EE-13 are due to OMB directives, there is a
program change of +50,280 in burden hours. Due to the slight
reduction in the number of claimants, there is also an adjustment
of -20,156 in burden hours.
16. Data collected with these forms will not be published.
17. The forms will display the OMB number and expiration date.
18. There are no exceptions to certification.

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