SS for renewal of 1240-0002

SUPPORTING STATEMENT

ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT FORMS (VARIOUS)

OMB NO. 1240-0002

A. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

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. 1240-0002: 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. OMB Control No. 1240-0002 also currently contains the information collection requirement found in the Act at 42 U.S.C. § 7385s-11.

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 of a deceased employee to file a claim under Part B and/or E of EEOICPA. It requests information on both the survivor and the deceased employee. It also requests information about illnesses, tort suits, settlements or awards in 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 DOE contractors to substantiate periods of unverified employment. There is no standard form or format for the submission of the information. 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-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 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-11A -- Letter to claimant about impairment benefits under Part E, sent with enclosure EN-11A, used to obtain medical evidence necessary to support an initial award for permanent impairment due to an accepted “covered illness.” (20 CFR 30.905 and 30.907)

EE-11B -- Letter to claimant about wage-loss benefits under Part E, sent with enclosure EE-11B, used to obtain the factual and medical evidence necessary to support an initial award for wage-loss benefits due to an accepted “covered illness.” (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 awarded state workers’ compensation for their covered illnesses. (42 USC 7385s-11)

EE-16 -- Letter to claimant, sent with enclosure EN-16, used to verify/obtain updated information about tort suits, settlements or awards in litigation, state workers’ compensation benefits, and fraud convictions that impact entitlement immediately prior to issuance of a recommended decision on the claim. (20 CFR 30.505 and 30.620)

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. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

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 is entitled to compensation under Part B and/or E of EEOICPA, and the amount of that compensation.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act, the current Forms EE-1, EE-2, EE-3 and EE-4 are posted on the Internet at http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm. A claimant may complete the form online and print out a paper copy and mail it to OWCP. The current Form EE-7 is also posted on the Internet at the same URL, the Form EE-7 only informs claimants of the type of medical evidence they must submit in support of their claims. Once the extension to OMB Control No. 1240-0002 is approved, the currently posted versions of these forms will be replaced with revised versions.

The EE-5A, EE-5B, and EE-7A are non-form collection requirements and do not have a “form” to be posted on the Internet. The Form EE-5 is not a “public” form subject to GPEA, and the Form EE-16 and Form EE-20 require original signatures for audit purposes, so they are also not posted on the Internet. Forms EE-10, EE-11A, EE-11B and EE-12 are only sent to claimants at a particular time and at a particular stage in the claims adjudication process, so it is impractical for OWCP to make these forms electronically interactive and post them on the Internet since doing so would likely lead to their improper use by respondents.  The Form 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 Forms EE-8 and EE-9 are claims development letters, generated by claims examiners, and are contained in OWCP’s word processing software.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

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. If the collection information impacts small businesses or other small entities), describe any methods used to minimize burden.

The information collections in OMB Control No. 1240-0002 have been streamlined to obtain the necessary information while imposing the minimum burden on the respondent. This information collection imposes a burden on individuals, rather than small businesses or other small entities. The Forms EE-7, EE-7A and EE-11A do not impose any additional burden on small businesses or other small entities since providing medical evidence is part of the medical providers’ usual business practices. This information collection does not have a significant economic impact on a substantial number of small businesses.

6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

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.

7. Explain any special circumstances required in the conduct of this information.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.

No outside consultants were contacted concerning the use of these forms. A Federal Register Notice inviting comments was published on July 5, 2013 (78FR40513). No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to a respondent, other than compensation payments.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

The information collected by OMB Control No. 1240-0002 is fully protected under the Privacy Act in the system of records known as DOL/ESA-49.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature on these forms.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information.

The chart below shows the projected burden hours based on a total estimated number of claims filed annually of 10,963. Burden hour estimates have been derived from actual data for FY 2012.

Require- Time To Freq. Number of Number of Hours

ment Complete of Resp. Respondents Responses Burden

EE-1 17 min. 1 4260 4260 1,207

EE-2 17 min. 1 6703 6703 1,899

EE-3 60 min. 1 7172 7172 7,172

EE-4 30 min. 1 1524 1524 762

EE-5A 30 min. 1 1327 1327 664

EE-5B 30 min. 20 53 1060 353

EE-7 15 min. 1 7172 7172 1,793

EE-7A 15 min. 1 353 353 88

EE-8 5 min. 1 160 160 12 EE-9 5 min. 1 430 430 36 EE-10 5 min. 1 4109 4109 342 EE-11A 15 min. 1 4123 4123 1,031

EE-11B 30 min. 1 390 390 195

EE-12 20 min. 1 9246 9246 3,082

EE-13 16 hrs. 1 51 51 816

EE-16 20 min. 1 8970 8970 2,990

EE-20 5 min. 1 8970 8970 748

TOTALS 65,013 66,020 23,190

The requirements have a total respondent burden hour estimate of 23,190. Using the March 2013 national average nonfarm private hourly wage of $23.82 from the Bureau of Labor Statistics, the respondent cost estimate for these requirements is $552,385.80 (23,190 x $23.82 = $552,385.80).

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

The only operation and maintenance cost for respondents in OMB Control No. 1240-0002 is for mailing. Since Forms EE-3 and/or EE-4 always accompany the Form EE-1 or Form EE-2, an estimated annual total of 57,324 mailed responses at $.46 + $.03 (postage + envelope) per response = $28,088.76.

14. Provide estimates of annualized cost to the Federal Government.

Federal Cost Estimate:

Review Costs:

Reviewer

Time Total (GS-11/4

Requirement to Review Responses Hourly*) Cost

EE-1 5 min. 4260 $30.26 $ 10,742.30

EE-2 5 min. 6703 $30.26 $ 16,902.73

EE-3 15 min. 7172 $30.26 $ 54,256.18

EE-4 15 min. 1524 $30.26 $ 11,529.06

EE-5A 10 min. 1327 $30.26 $ 6,692.50

EE-5B 10 min. 1060 $30.26 $ 5,345.93

EE-7 15 min. 7172 $30.26 $ 54,256.18

EE-7A 15 min. 353 $30.26 $ 2,670.45

EE-8 3 min. 160 $30.26 $ 242.08

EE-9 3 min. 430 $30.26 $ 650.59

EE-10 5 min. 4109 $30.26 $ 10,361.53

EE-11A 10 min. 4123 $30.26 $ 20,793.66

EE-11B 10 min. 390 $30.26 $ 1,966.90

EE-12 5 min. 9246 $30.26 $ 23,315.33

EE-13 8 hrs. 51 $30.26 $ 12,346.08

EE-16 30 min. 8970 $30.26 $135,761.10

EE/EN-20 5 min. 8970 $30.26 $ 22,619.35

*Using Salary Table 2012-RUS

Total number of responses (annually)..66,020

Total time to review..................12,903 Hours

Total Review Cost.....................$390,451.95

Printing................................$1,000.00

Mailing (forms are submitted to the

Federal government; there is potential

Federal postage cost for EE-20).........$4,395.30

Total Federal Cost....................$395,847.25

15. Explain the reasons for any program changes or adjustments.

The numbers in the 2010 Supporting Statement had miscalculations and were entered into ROCIS; therefore the "Change Due to Adjustment in Agency Estimate" numbers have been adjusted to reflect the revisions.

There is an overall adjustment of +5,713 in burden hours. This is partially due to a shift in the type of claims being adjudicated to those that require the submission of more information. There has also been an increase in the operation and maintenance cost of +$25,772. This is partially due to mailing costs increasing.

The only change to any of the forms in this renewal was to the form EE/EN-20. The only changes were the deletion of the option to request payment by paper check, per Treasury’s instructions.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

Data collected with these forms will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

The forms will display the OMB number and expiration date.

18. Explain each exception to the certification statement in ROCIS.

There are no exceptions to certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

10