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 Requisitos medicos segun la Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de la Energia	Form and Instruction	Modified	Available
Form EE-7 English Medial Requirements under rhe Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-4 Spanish Declaracion jurada sobre historial de empleo para reclamacion sequin la Ley del Programa de Indemnizacioon por Enfermedades Ocupacionales para Empleados del Sector de la Energia	Form and Instruction	Modified	Available
Form EE-3 Spanish Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia	Form and Instruction	Modified	Available
Form EE-2 Spanish Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia	Form and Instruction	Modified	Repair queued
Form EE-1 Spanish Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia	Form and Instruction	Modified	Available
Form EE-20 and EN-20 Letter to Claimant	Form and Instruction	Modified	Available
Form EE_10 and EN-10 Letter to Claimant	Form	Modified	Available
Form EE-9 and EN-9 Letter to Claimant	Form	Modified	Available
Form Form EE-8 and EN-8 Letter to Claimant	Form	Modified	Available
Form EE-4 English Employment History Affidavit for a Claim 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-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
SS for revision to 1240-0002 (05-12-2010) (2).doc	Supporting Statement A	Uploaded 2010-05-13	Available
Supporting regulations 1240-0002.doc	Supplementary Document	Uploaded 2010-04-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
178684	EEOICP Forms for Federal Government	Other-EEOICP forms for State Government	Modified
178683	EEOICP Forms for Business or other for profits	Form and Instruction	Modified	Requisitos medicos segun la Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de la Energia
178683	EEOICP Forms for Business or other for profits	Form and Instruction	Modified	Medial Requirements under rhe Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Declaracion jurada sobre historial de empleo para reclamacion sequin la Ley del Programa de Indemnizacioon por Enfermedades Ocupacionales para Empleados del Sector de la Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Letter to Claimant
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	Modified	Letter to Claimant
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	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	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act

ICR Details

OMB Control No: 1240-0002	ICR Reference No: 201004-1240-002
Status: Historical Active	Previous ICR Reference No: 201003-1240-002
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: 10/08/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/09/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	10/31/2010
Responses	36,966	0	79,062
Time Burden (Hours)	17,477	0	35,447
Cost Burden (Dollars)	2,317	0	4,629

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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 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 42 USC 7385(s) through 11 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:
	75 FR 10504	03/08/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 47029	08/04/2010
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 English, EE-7 Spanish	Medial Requirements under rhe Energy Employees Occupational Illness Compensation Program Act ,   Requisitos medicos segun la Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de la Energia
EEOICP Forms for Federal Government
EEOICP Forms for Individuals or Households	EE_10 and EN-10, EE-20 and EN-20, EE-4 Spanish, EE-2 Spanish, EE-1 Spanish, EE-3 English, EE-3 Spanish, EE-1 English, EE-2 English, EE-4 English, EE-9 and EN-9, Form EE-8 and EN-8	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act ,   Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia ,   Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia ,   Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia ,   Declaracion jurada sobre historial de empleo para reclamacion sequin la Ley del Programa de Indemnizacioon por Enfermedades Ocupacionales para Empleados del Sector de la Energia

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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	36,966	79,062	0	-42,096	0	0
Annual Time Burden (Hours)	17,477	35,447	0	-17,970	0	0
Annual Cost Burden (Dollars)	2,317	4,629	0	-2,312	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There is an overall adjustment of -13,718 in burden hours due to a decrease in the number of claimants from prior years. There has also been an increase in the operation and maintenance cost of +$18,152 since mailing costs have increased from $4,629 to 22, 781.

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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]? No

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)? No

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: 08/09/2010

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