Dol/esa-49

DOL ESA-49 (EEOICPA).doc

Medical Travel Refund Request

DOL/ESA-49

OMB: 1240-0037

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DOL/ESA–48

SYSTEM NAME:

‘‘Customer Service component’’ of the Wage Hour Investigative Support and Reporting Database (WHISARD).

SECURITY CLASSIFICATION:

None.

SYSTEM LOCATION:

Wage and Hour National Office (NO), Regional Offices (RO) and District Offices (DO), see The Appendix of this document for addresses.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

Persons who contact the Wage and Hour Division for technical assistance or to file a complaint.

CATEGORIES OF RECORDS IN THE SYSTEM:

‘‘Browse Customer List’’ records containing last name, first name, phone number, address, city, complaint status, case identification number, WH employee name, and contact priority.

‘‘Employee Contact Information’’ records containing home address, phone numbers, fax number, e-mail address and certain information about the individual’s complaint.

‘‘Employee Work Information’’ records containing certain employment and payroll information about the individual’s complaint.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

5 U.S.C. 301; 29 U.S.C. 201 et seq.

PURPOSE(S):

To provide Wage and Hour NO, ROS and DOs with an index of individuals who contact the Wage and Hour Division. This information may be used to provide assistance or facilitate the processing of a complaint.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:

In addition to the routine uses listed in the General Prefatory Statement to this document, relevant information may be provided to other government agencies for law enforcement purposes.

DISCLOSURE OF CONSUMER REPORT AGENCIES:

None.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING AND DISPOSING OF RECORDS IN THE SYSTEM:

STORAGE:

Maintained in an electronic file Database in the DOL National Office.

RETRIEVABILITY:

By name of the individual.

SAFEGUARDS:

Only authorized personnel have access by use of passwords to this on­line transactional system and its database.

RETENTION AND DISPOSAL:

Printed investigation forms generated by the WHISARD system will be retained in the investigative files of Wage and Hour District Offices (see Records Disposal Schedule #NN–168– 43, items 1a and 1b which provides as follows: Printed information, concerning cases where violations were found, is disposed of 12 years after the date the case is closed. For cases where no violation were found, printed information is disposed of three years after the closing date. Database information will be captured on tape at the end of each fiscal year and retained for 25 years.

SYSTEM MANAGER(S) AND ADDRESS:

Administrator, Wage and Hour Division, Room S–3502, Frances Perkins Building, 200 Constitution Avenue, NW, Washington, DC 20210.

NOTIFICATION PROCEDURES:

Individuals wishing to make inquiries regarding this system should contact the system manager, or the regional office servicing the state where they are employed (see list of the regional office addresses in the Appendix of this document).

RECORD ACCESS PROCEDURES:

Individuals wishing to request access to these records should contact the appropriate office listed in the Appendix.

CONTESTING RECORD PROCEDURES:

Individuals wishing to contest or amend any records should direct their request to the appropriate system manager. In addition, the request should state clearly and concisely what information is being contested, the reason for contesting it, and the proposed amendment sought for the information.

RECORD SOURCE CATEGORIES:

Complainants, employers, and Wage and Hour personnel.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:

None.


DOL/ESA–49

SYSTEM NAME:

Office of Workers’ Compensation Programs, Energy Employees Occupational Illness Compensation Program Act File.

SECURITY CLASSIFICATION:

Most files and data are unclassified. Files and data in certain cases have Top Secret classification, but the rules concerning their maintenance and disclosure are determined by the agency that has given the information the security classification of Top Secret.

SYSTEM LOCATION:

U.S. Department of Labor,Employment Standards Administration, Office of Workers’ Compensation Programs, Frances Perkins Building, 200 Constitution Ave., NW, Washington, DC 20210, and district offices located throughout the United States.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

Individuals or their survivors who claim benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). These individuals include, but are not limited to, federal employees or survivors of federal employees; employees or survivors of employees of the Department of Energy, its predecessor agencies, and their contractors and subcontractors; and members of the armed forces.

CATEGORIES OF RECORDS IN THE SYSTEM:

This system may contain the following kinds of records: Claim forms filed by or on behalf of injured individuals or their survivors seeking benefits under the EEOICPA; reports by the employee and/or the U.S. Department of Energy; employment records; exposure records; safety records or other incident reports; dose reconstruction records; workers’ or family members contemporaneous diaries, journals, or other notes; forms authorizing medical care and treatment; other medical records and reports; bills and other payment records; compensation payment records; formal orders for or against the payment of benefits; transcripts of hearings conducted; and any other medical, employment, or personal information submitted or gathered in connection with the claim. The system may also contain information relating to dates of birth, marriage, divorce, and death; notes of telephone conversations conducted in connection with the claim; information relating to vocational and/ or medical rehabilitation plans and progress reports; records relating to court proceedings, insurance, banking and employment; articles from newspapers and other publications; information relating to other benefits (financial and otherwise) the claimant may be entitled to, including previously filed claims; and information received from various investigative agencies concerning possible violations of Federal civil or criminal law.

The system may also contain consumer credit reports on individuals indebted to the United States, information relating to the debtor’s assets, liabilities, income and expenses, personal financial statements, correspondence to and from the debtor, information relating to the location of the debtor, and other records and reports relating to the implementation of the Federal Claims Collection Act (as amended), including investigative reports or administrative review matters. Individual records listed here are included in a claim file only insofar as they may be pertinent or applicable to the individual claiming benefits.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

Energy Employees Occupational Illness Compensation Program Act, Title XXXVI of Pub. L. 106–398, October 30, 2000, 114 Stat. 1654.

PURPOSE(S):

To maintain records on individuals who file claims under the Energy Employees Occupational Illness Compensation Program Act, which establishes a program for compensating certain individuals for covered illnesses related to exposure to beryllium, cancers related to exposure to radiation, and chronic silicosis. These records provide information and verification about individual claimants’ covered illnesses on which may be based any entitlement to medical treatment, compensation and survivors’ benefits, under the EEOICPA and certain other statutes.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSE OF SUCH USES:

In addition to those Department-wide routine uses set forth above in the General Prefatory Statement to this document, disclosure of information from this system of records may be made to the following individuals and entities for the purposes noted when the purpose of the disclosure is both relevant and necessary and is compatible with the purpose for which the information was collected:

a. To any attorney or otherrepresentative of an EEOICPA beneficiary for the purpose of assisting in a claim or litigation against a third party or parties potentially liable to pay damages as a result of the beneficiary’s compensable condition, and for the purpose of administering the provisions of sections 3641–3642 of the EEOICPA.

Any such third party, or a representative acting on that third party’s behalf, may be provided information or documents concerning the existence of a record and the amount and nature of compensation paid to or on behalf of the beneficiary for the purpose of assisting in the resolution of the claim or litigation against that party or administering the provisions of sections 3641–3642 of the EEOICPA.

b. To the Department of Energy, itscontractors and subcontractors, and federal agencies that employed the employee at the time of the alleged exposure of the employee, and to other entities that may possess relevant information, to assist in administering the EEOICPA, to answer questions about the status of the claim, to consider other actions the agency may be required to take with regard to the claim, or to permit the agency to evaluate its safety and health program. Disclosure to federal agencies, including the Department of Justice, may be made where OWCP determines that such disclosure is relevant and necessary for the purpose of providing assistance in regard to asserting a defense based upon the EEOICPA’s exclusive remedy provision to an administrative claim or to litigation filed under the Federal Tort Claims Act.

c. To the personnel, contractors,grantees, and cooperative agreement holders of the Department of Energy, the Department of Health and Human Services, the Department of Justice, and other federal agencies designated by the President to implement the federal compensation program established by the EEOICPA, for the purpose of assisting in the adjudication or processing of a claim under that Act.

d. To physicians, pharmacies, andother health care providers for their use in treating the claimant, in conducting an examination or preparing an evaluation on behalf of OWCP and for other purposes relating to the medical management of the claim, including evaluation of and payment for charges for medical and related services and supplies.

e. To medical insurance or health andwelfare plans (or their designees) that cover the claimant in instances where OWCP had paid for treatment of a medical condition that is not compensable under the EEOICPA, or where a medical insurance plan or health and welfare plan has paid for treatment of a medical condition that may be compensable under the EEOICPA, for the purpose of resolving the appropriate source of payment in such circumstances.


f. To a federal, state or local agencyfor the purpose of obtaining information relevant to a determination concerning initial or continuing eligibility for EEOICPA benefits, and for a determination concerning whether benefits have been or are being properly paid, including whether dual benefits that are prohibited under any applicable federal or state statute are being paid; and for the purpose of utilizing salary offset and debt collection procedures, including those actions required by the Debt Collection Act of 1982, to collect debts arising as a result of overpayments of EEOICPA compensation and debts otherwise related to the payment of EEOICPA benefits.

g. To the Internal Revenue Service(IRS) for the purpose of obtaining taxpayer mailing addresses for the purposes of locating a taxpayer to collect, compromise, or write-off a federal claim against such taxpayer; and informing the IRS of the discharge of a debt owed by an individual. Records from this system of records may be disclosed to the IRS for the purpose of offsetting a federal claim from any income tax refund that may be due to the debtor.

h. Where an investigation, settlementof claims, or the preparation and conduct of litigation is undertaken, a record may be disclosed to (1) a person representing the United States or the Department of Labor in the investigation, settlement or litigation, and to individuals assisting in such representation; (2) others involved in the investigation, settlement, and litigation, and their representatives and assistants; and (3) a witness, potential witness, or their representatives and assistants, and to any other person who possesses information pertaining to the matter, when such disclosure is necessary for the conduct of the investigation, settlement, or litigation, or is necessary to obtain information or testimony relevant to the matter.

i. To the Defense Manpower DataCenter—Department of Defense and the United States Postal Service to conduct computer matching programs for the purpose of identifying and locating individuals who are receiving Federal salaries or benefit payments and are delinquent in their repayment of debts owed to the United States under programs administered by the DOL in order to collect the debts under the provisions of the Debt Collection Act of 1982 (Pub. L. 97–365) by voluntary repayment, or by salary or administrative offset procedures.

j. To a credit bureau for the purposeof obtaining consumer credit reports identifying the assets, liabilities,


expenses, and income of a debtor in order to ascertain the debtor’s ability to repay a debt incurred under the FECA, to collect the debt, or to establish a payment schedule.

k. The amount, status and history ofoverdue debts, the name and address, taxpayer identification (SSN), and other information necessary to establish the identity of a debtor, the agency and program under which the claim arose, may be disclosed pursuant to 5 U.S.C. 552a(b)(12) to consumer reporting agencies as defined by section 603(f) of the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or in accordance with section 3(d)(4)(A)(ii) of the Federal Claims Collection Act of 1966 as amended (31

U.S.C. 3711(f)) for the purpose ofencouraging the repayment of an overdue debt.

l. To individuals, and their attorneysand other representatives, and government agencies, seeking to enforce a legal obligation on behalf of such individual or agency, to pay alimony and/or child support for the purpose of enforcing such an obligation, pursuant to an order of a state or local court of competent jurisdiction, including Indian tribal courts, within any State, territory or possession of the United States, or the District of Columbia or to an order of a State agency authorized to issue income withholding notices pursuant to State or local law or pursuant to the requirements of section 666(b) of title 42, United States Code, or for the purpose of denying the existence of funds subject to such legal obligation.

m. To the spouse, children, parents,grandchildren, or grandparents of deceased employees who may be covered under the EEOICPA to enable them to determine their eligibility for benefits under the EEOICPA, and to inform them of decisions regarding benefit eligibility, so that they have the opportunity to take action to protect any rights they may have as potentially eligible beneficiaries.


Note: Disclosure of information contained in this system of records to the subject of the record, a person who is duly authorized to act on his or her behalf, or to others to whom disclosure is authorized by these routine uses, may be made over the telephone or by electronic means. Disclosure over the telephone or by electronic means will only be done where the requestor provides appropriate identifying information. Telephonic or electronic disclosure of information is essential to permit efficient administration and adjudication of claims under the EEOICPA.

DISCLOSURE TO CONSUMER REPORTING AGENCIES:

The amount, status and history of overdue debts, the name and address, taxpayer identification (SSAN), and other information necessary to establish the identity of a debtor, the agency and program under which the claim arose, may be disclosed pursuant to 5 U.S.C. 552a(b)(12) to consumer reporting agencies as defined by section 603(f) of the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or in accordance with section 3(d)(4)(A)(ii) of the Federal Claims Collection Act of 1966 as amended (31

U.S.C. 3711(f)) for the purpose ofencouraging the repayment of an overdue debt.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING AND DISPOSING OF RECORDS IN THE SYSTEM:

STORAGE:

Paper case files are maintained in filing cabinets. Automated data, including case files that have been transformed into electronic form, are stored in computer discs or magnetic tapes, which are stored in cabinets. Microfiche is stored in cabinets.

RETRIEVABILITY:

Files and automated data are retrieved after identification by coded file number and/or Social Security Number which is cross-referenced to employee by name, employer and/or contractor, and date and nature of injury.

SAFEGUARDS:

Files and automated data are maintained under supervision of OWCP personnel during normal working hours—only authorized personnel, with the appropriate password, may handle, retrieve, or disclose any information contained therein. Access to electronic records is controlled by password or other user identification code.

RETENTION AND DISPOSAL:

All case files and automated data pertaining to a claim are destroyed 15 years after the case file has become inactive. Paper files that have been scanned to create electronic copies are destroyed after the copies are verified. Automated data is retained in its most current form only, however, and as information is updated, outdated information is deleted. Some related financial records are retained only in electronic form, and destroyed 6 years and 3 months after creation or receipt.

SYSTEM MANAGER(S) AND ADDRESS:

Director, Office of Workers’ Compensation Programs, 200 Constitution Avenue, NW, Washington, DC 20210.

NOTIFICATION PROCEDURES:

An individual wishing to inquire whether this system of records contains information about him/her may write or telephone the OWCP district office that services the state in which the individual resided or worked at the time he or she believes a claim was filed. In order for the record to be located, the individual must provide his or her full name, OWCP claim number (if known), date of injury (if known), and date of birth.

RECORD ACCESS PROCEDURES:

Any individual seeking access to non­exempt information about a case in which he/she is a party in interest may write or telephone the OWCP district office where the case is located, or the systems manager.

CONTESTING RECORD PROCEDURES:

Any individual requesting amendment of non-exempt records should contact the appropriate OWCP district office, or the system manager. Individuals requesting amendment of records must comply with the Department’s Privacy Act regulations at 29 CFR 71.1 and 71.9.

RECORD SOURCE CATEGORIES:

Injured employees who are the subjects of the record, their family members and beneficiaries; employing Federal agencies; State governments, State agencies, and other Federal agencies; State and Federal workers’ compensation offices; physicians and other medical professionals; hospitals; clinics; medical laboratories; suppliers of health care products and services and their agents and representatives; educational institutions; attorneys; Members of Congress; OWCP field investigations; consumer credit reports; investigative reports; correspondence with the debtor including personal financial statements; records relating to hearings on the debt; and other DOL systems of records.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:

In accordance with 5 U.S.C. 552a(k)(2), investigative material in this system of records compiled for law enforcement purposes is exempt from subsections (c)(3), (d), (e)(1), (e)(4)(G),

(H) and (I), and (f) of 5 U.S.C. 552a,provided, however, that if any individual is denied any right, privilege, or benefit that he or she would otherwise be entitled to by Federal law, or for which he or she would otherwise be eligible, as a result of the maintenance of these records, such material shall be provided to the individual, except to the extent that the disclosure of the material would reveal the identity of a source who furnished information to the Government under an express promise that the identity of the source would be held in confidence, or prior to January 1, 1975, under an implied promise that the identity of the source would be held in confidence.


DOL/ESA–50

SYSTEM NAME:

Office of Workers’ Compensation Programs, Physicians and Health Care Providers Excluded under the Energy Employees Occupational Illness Compensation Program Act.

SECURITY CLASSIFICATION:

None.

SYSTEM LOCATION:

U.S. Department of Labor,Employment Standards Administration, Office of Workers’ Compensation Programs, Frances Perkins Building, 200 Constitution Ave., NW, Washington, DC 20210.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

Providers of medical goods and services, including physicians, hospitals, and providers of medical support services or supplies excluded or considered for exclusion from payment under the Energy Employees Occupational Illness Compensation Program Act for fraud or abuse (20 CFR 30.715–30.726, or as updated).

CATEGORIES OF RECORDS IN THE SYSTEM:

Copies of letters, lists and documents from Federal and state agencies concerning the administrative debarment of providers from participation in programs providing benefits similar to those of the Energy Employees Occupational Illness Compensation Program Act and their reinstatement; materials concerning possible fraud or abuse which could lead to exclusion of a provider; documents relative to reinstatement of providers, materials concerning the conviction of providers for fraudulent activities in connection with any Federal or state program for which payments are made to providers for similar medical services; all letters, memoranda, and other documents regarding the consideration of a provider’s exclusion, the actual exclusion, or reinstatement under the provisions of 20 CFR 30.715–30.726 (or as updated); copies of all documents in a claim file relating to medical care and/ or treatment including bills for such services, as well as letters, memoranda, and other documents obtained during investigations, hearings and other administrative proceedings concerning exclusion for fraud or abuse, as well as reinstatement, along with recommendations and decisions; lists of excluded providers released by the OWCP.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

Energy Employees Occupational Illness Compensation Program Act, Title XXXVI of Pub. L. 106–398, October 30, 2000, 114 Stat. 1654.

PURPOSE(S):

To maintain records in order to determine the propriety of instituting debarment actions under the Energy Employees Occupational Illness Compensation Program Act. These records also provide information on treatment, billing and other aspects of a medical provider’s actions, and/or documentation relating to the debarment of the medical care provider under another Federal or state program.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSE OF SUCH USES:

In addition to those universal routine uses listed in the General Prefatory Statement to this document, disclosure of information from this system of records may be made to the following individuals and entities for the purposes noted when the purpose of the disclosure is compatible with the purpose for which the information is collected:

a. Federal, state or local governmentagencies, state licensing boards, professional organizations, claimants, patients, employers, insurance companies, and any other entities or individuals, for the purpose of identifying an excluded or reinstated provider, to ensure that authorization is not issued nor payment made to an excluded provider, and for the purpose of providing notice that a formerly excluded provider has been reinstated.

b. Federal, state or local governmentagencies, state licensing boards, professional organizations, claimants, patients, employers, insurance companies, and any other entities or individuals, for the purpose of obtaining information necessary to ensure that the list of excluded providers is correct, useful, and updated, as appropriate, and for the purpose of obtaining information relevant to a Departmental decision regarding a debarment action. This routine use encompasses the disclosure of such information that will enable the Department to properly verify the identity of a provider, to identify the nature of a violation, and the penalty imposed for such violation.


Note: Disclosure of information contained in the file to the claimant, a person who is duly authorized to act on his/her behalf, or to others to whom disclosure is authorized by these routine uses, may be made over the telephone. Disclosure over the telephone will only be done where the requestor provides appropriate identifying information. Telephonic disclosure of information is essential to permit efficient administration and adjudication of claims.

DISCLOSURE TO CONSUMER REPORTING AGENCIES:

None.

POLICIES AND PROCEDURES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THIS SYSTEM:

STORAGE:

The records are in manual files, magnetic tapes or other computer storage media, or on computer printouts.

RETRIEVABILITY:

Material is retrieved either by the name of the provider, a case citation, or date of release.

SAFEGUARDS:

Files and automated data are maintained under supervision of OWCP personnel during normal working hours—only authorized personnel, with the appropriate password, may handle, retrieve, or disclose any information contained therein. Access to electronic records is controlled by password or other user identification code.

RETENTION AND DISPOSAL:

File is retained in the office for three years after the debarment action is final and then transferred to the Federal Records Center, and destroyed thirty years after the debarment action is final. Where the period of exclusion is defined as a set period of time, the file will be retained two years after the period of exclusion expires (or the individual is otherwise reinstated), then transferred to the Federal Records Center, and destroyed thirty years after the debarment action is final.

SYSTEM MANAGER(S) AND ADDRESS:

Director, Office of Workers’ Compensation Programs, 200 Constitution Avenue, NW, Washington, DC 20210.

NOTIFICATION PROCEDURE:

An individual wishing to inquire whether this system of records contains information about him/her may write the system manager at the address above. In order for the record to be located, the individual must provide his or her full name, date of birth, and signature.


File Typetext/rtf
File TitleDocument
SubjectExtracted Pages
AuthorU.S. Government Printing Office
File Modified2006-03-30
File Created2002-05-03

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