Form EE-7 English EE-7 English Medial Requirements under rhe Energy Employees Occupatio

Medical Requirements under the Energy Employees Occupational Illness Compensation Program Act					U.S. Department of Labor Office of Workers’ Compensation Programs Division of Energy Employees Occupational Illness Compensation
						OMB No. 1240-0002 Expiration Date: XX/XX/20XX
General Medical Requirements
All claims filed under EEOICPA must include a medical report(s) providing:
	• History of the claimed illness or death
	• Physical examination and its findings
	• Clinical laboratory tests performed and discussion of the results
	• Diagnosis (ICD-9 coded, if possible) and the date when it was first documented
Claims for Radiogenic Cancer must include:
		• 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
		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
Part B – Medical Requirements
		Under Part B, compensable illnesses are limited to Beryllium Sensitivity, Established Chronic Beryllium Disease, Chronic Silicosis and Radiogenic Cancer.
		Beryllium Sensitivity
			• Abnormal Beryllium Lymphocyte Proliferation Test (LPT) performed on blood or lung lavage cells
		Chronic Beryllium Disease
		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
			• Computerized axial tomography scan showing changes consistent with chronic beryllium disease
			• 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:
			• Chest radiograph or computed tomography denoting characteristic abnormalities
			• Restrictive or obstructive lung physiology test or diffusion lung capacity defect
			• Lung pathology consistent with chronic beryllium disease
			• Clinical course consistent with chronic respiratory disease disorder
			• Immunologic tests showing beryllium sensitivity (skin patch test or beryllium test preferred)
		Chronic Silicosis
		Ten year onset latency period and one (1) of the following:
			• 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
			• Lung biopsy consistent with silicosis
Part E - Medical Requirements
Under Part E, any illness caused by occupational exposure to toxic substances can be claimed. A toxic substance is any material that has the potential to cause illness or death because of its radioactive, chemical, or biological nature. Medical evidence must show that exposure to toxic substances was a significant factor that “at least as likely as not” caused, contributed to, or aggravated the claimed illness and/or death; and that it is “at least as likely as not” that this exposure was related to covered employment at a Department of Energy facility or RECA Section 5 facility. In the absence of diagnostic medical evidence, a death certificate, signed by a physician, may be submitted to establish a diagnosis and cause of death.

Form EE-7

April 2013

Page 1

EE-7 Instructions

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 claimed condition(s). Medical evidence to support claims under either Part B or Part E 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. Please maintain a copy of all documents for your records.

Privacy Act Statement

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 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) 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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to the information collections on this form unless it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 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. The obligation to respond to this collection is required to obtain EEOICPA benefits (20 CFR 30.103, 30.207, 30.215, 30.222, 30.232, 30.415, 30.416 and 30.417). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers’ Compensation Programs, Room S3524, 200 Constitution Avenue N.W., Washington, D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE-7. Do not submit the completed form to this address.

Form EE-7

April 2013

Page 2