EEOICP Forms for State Governments

Energy Employees Occupational Illness Compensation Program Act Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0002 can be found here:

Documents and Forms

Document Name Document Type
EE-13 and EN-13 (draft for 2013 clearance).docx Other-EEOICP forms for State Governm

Information Collection (IC) Details

IC Title:	EEOICP Forms for State Governments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-EEOICP forms for State Government			EE-13 and EN-13 (draft for 2013 clearance).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-49	FR Citation: 67 FR 16891

Number of Respondents: 2,438	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,438	2,387	51
Annual IC Time Burden (Hours)	1,833	1,017	816
Annual IC Cost Burden (Dollars)	1,195	1,195	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.