Energy Employees Occupational Illness Compensation Program Act Forms

Forms and Documents

Document Name	Status
Form EE-13 and EN-13 EEOICP Forms for State Governments Form	Modified
Form EE-7 English EEOICP Forms for Private Sector Form and Instruction	Modified
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction	Modified
Supporting Regulations.pdf Supplementary Document	2013-06-11
Supporting statement for REVISION to 1240-0002 Rulemaking.docx Supporting Statement A	2015-10-02

IC Document Collections

IC ID	Document Title	Status
178684	EEOICP Forms for State Governments Form	Modified
178683	EEOICP Forms for Private Sector Form and Instruction	Modified
13934	EEOICP Forms for Individuals or Households Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0002	ICR Reference No: 201510-1240-002
Status: Historical Inactive	Previous ICR Reference No: 201304-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Energy Employees Occupational Illness Compensation Program Act Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 01/19/2016
	Date Received in OIRA: 11/18/2015
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved	03/31/2017
Responses	66,020	0	66,020
Time Burden (Hours)	23,190	0	23,190
Cost Burden (Dollars)	28,089	0	28,089

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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:
1240-AA08	Proposed rulemaking	80 FR 72296	11/18/2015

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 72269	11/18/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
EEOICP Forms for Private Sector	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 State Governments	EE-13 and EN-13	EEOICP forms for State Workers' Compensation Agency
EEOICP Forms for Individuals or Households	EE-17B, EE-17A, 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, EE-11A and EN-11A, EE-11B and EN-11B, EE-12 and EN-12, EE-16 and EN-16	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 ,   Letter to Claimant EE-8 and EN-8 ,   Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant EE-9 and EN-9 ,   Letter to Claimant EE-10 and EN-10 ,   Letter to Claimant EE-20 and EN-20 ,   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 ,   Letter to Claimant EE-11A and EN-11A ,   Letter to Claimant EE-11B and EN-11B ,   Letter to Claimant EE-12 and EN-12 ,   Letter to Claimant EE-16 and EN-16 ,   Physician's Certification of Medical Necessity Under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Home Health Care, Nursing Home, or Assited Living Benefits Under the Energy Employees Occupational Programs Act

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

Burden Increase Due to: Miscellaneous Actions

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 +556 in burden hours due to a shift in the type of claims being adjudicated to those that require the submission of more information, and the new EE-17A and EE-17B; this increase has been offset by a reduction in the amount of burden hours for other requirements in Control No. 1240-0002. There has also been an increase in the operation and maintenance costs of +$3,414, due to new responses and increased mailing costs, from $28,089 to $31,503.

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Annual Cost to Federal Government: $329,173

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]? 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: 11/18/2015

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