EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form B 42 CFR Part 83.9	Form	Modified	Available
Section B.docx	Supporting Statement B	Uploaded 2013-05-22	Available
Attachment B.pdf	Supplementary Document	Uploaded 2013-05-22	Available
Attachment A2.doc	Supplementary Document	Uploaded 2013-05-22	Available
Attachment A1.pdf	Supplementary Document	Uploaded 2013-05-22	Available
Attachment A.pdf	Supplementary Document	Uploaded 2013-05-22	Available
Attachment D1 SEC Form B Instructions.rev 2.pdf	Supplementary Document	Uploaded 2010-07-14	Available
Section A rev1 5 17 2013 (2).doc	Supporting Statement A	Uploaded 2013-05-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7107	Form A 42 CFR 83.9	Instruction	Modified
180186	Authorization Form on behalf of Claimant under 42 CFR 83.7	Instruction	Modified
180185	Petitioner Appealing Final Decision under 42 CFR 83.18	Instruction	Modified
180184	Petitioner Submission Format other than Form B 42 CFR 83.9	Instruction	Modified
180183	Form B 42 CFR Part 83.9	Form	Modified

ICR Details

OMB Control No: 0920-0639	ICR Reference No: 201305-0920-013
Status: Historical Active	Previous ICR Reference No: 201007-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 19659
Title: EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/01/2013
	Date Received in OIRA: 05/30/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	09/30/2013
Responses	23	0	100
Time Burden (Hours)	51	0	237
Cost Burden (Dollars)	0	0	0

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Abstract: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384-7385 [1994, supp. 2001], established a compensation program to provide a lump sum payment of $150,000 and medical benefits as compensation to covered employees suffering from designated illnesses incurred as a result of their exposure to radiation, beryllium, or silica while in the performance of duty for the Department of Energy and certain of its vendors, contractors and subcontractors. Among other duties, the executive order directed HHS to establish and implement procedures for considering petitions by classes of nuclear weapons workers to be added to the "Special Exposure Cohort" (the "Cohort"), a cohort of various groups of workers selected by Congress whose claims for cancer under EEOICPA can be adjudicated without demonstrating that their cancer was "at least as likely as not" caused by radiation doses they incurred in the performance of duty. In brief, EEOICPA authorizes HHS to designate such classes of employees for addition to the Cohort when HHS lacks sufficient information to estimate with sufficient accuracy the radiation doses of the employees.

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Authorizing Statute(s): PL: Pub.L. 42 - 83 1 Name of Law: Procedures for Designating
   EO: EO 13179 Name/Subject of EO: Providing Compensation to America's Nuclear Weapons Workers
   US Code: 42 USC 7834 Name of Law: Employees Occupational Ilness Compensation Program Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA13	Final or interim final rulemaking	70 FR 75949	12/22/2005

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 18596	03/27/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 32252	05/29/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Form A 42 CFR 83.9
Authorization Form on behalf of Claimant under 42 CFR 83.7
Form B 42 CFR Part 83.9	none	Form B
Petitioner Submission Format other than Form B 42 CFR 83.9
Petitioner Appealing Final Decision under 42 CFR 83.18

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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	23	100	0	0	-77	0
Annual Time Burden (Hours)	51	237	0	0	-186	0
Annual Cost Burden (Dollars)	0	0	0	0	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: No

Burden Reduction Due to:

Short Statement: The estimated annual respondent burden hours has been reduced to reflect the actual level of use of these forms over the past two years.

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Annual Cost to Federal Government: $9,459

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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]? No

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: 05/30/2013

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