Information Collection

EEOICP Forms for Individuals or Households

IC 13934 under ICR 201510-1240-002 · OMB 1240-0002.

⚠️ Notice: This information collection may be referencing outdated material.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

2026-05-28 - No material or nonsubstantive change to a currently approved collection
2026-03-12 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EE-1 English EEOICP Forms for Individuals or Households	Form and Instruction
EE-1 English Worker's Claim for Benefits Under the Energy Employees O EE-1.docx www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and Instruction
EE-2 English Survivor's Claim for Benefits Under the Energy Employees EE-2.docx www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and Instruction
EE-3 English Employment History for a Claim Under The Energy Employee EE-3.docx www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and Instruction
EE-4 English Employment History Affidavit for a Claim Under the Energ EE-4.docx www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and Instruction
Form EE-8 and EN-8 Letter to Claimant EE-8 and EN-8 EE-8 with EN-8.docx	Form
EE-9 and EN-9 Letter to Claimant EE-9 and EN-9 EE-9 and EN-9 (draft for 2015 revision)DONE.docx	Form
EE-10 and EN-10 Letter to Claimant EE-10 and EN-10 EE-10 with EN-10.docx	Form
EE-20 and EN-20 Letter to Claimant EE-20 and EN-20 EE-20 with EN-20.docx	Form and Instruction
EE-1 Spanish Reclamacion de beneficios segun la Ley del Programa de I EE-1-Spa.docx www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Form and Instruction
EE-2 Spanish Reclaamacion de beneficios de sobreviviente segun las Le EE-2-Spa.docx www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Form and Instruction
EE-3 Spanish Historial de empleo para reclamacion segun la Ley del Pr EE-3-Spa.docx www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and Instruction
EE-4 Spanish Declaracion jurada sobre historial de empleo para reclam EE-4-Spa.docx www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Form and Instruction
EE-11A and EN-11A Letter to Claimant EE-11A and EN-11A EE-11A with EN-11A.docx	Form
EE-11B and EN-11B Letter to Claimant EE-11B and EN-11B EE-11B with EN-11B.docx	Form
EE-12 and EN-12 Letter to Claimant EE-12 and EN-12 EE-12 with EN-12.docx	Form
EE-16 and EN-16 Letter to Claimant EE-16 and EN-16 EE-16 with EN-16.docx	Form
EE-17B Physician's Certification of Medical Necessity Under the EE-17B.docx	Form and Instruction
EE-17A Claim for Home Health Care, Nursing Home, or Assited Liv EE-17A.docx	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

EEOICP Forms for Individuals or Households

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.103 20 CFR 30.206 20 CFR 30.102 20 CFR 30.111 20 CFR 30.417 20 CFR 30.505 20 CFR 30.620 20 CFR 30.207 20 CFR 30.806 20 CFR 30.212 20 CFR 30.221 20 CFR 30.113 20 CFR 30.100 20 CFR 30.114 20 CFR 30.213 20 CFR 30.231 20 CFR 30.415 20 CFR 30.416 20 CFR 30.214 20 CFR 30.222 20 CFR 30.101 20 CFR 30.215 20 CFR 30.226 20 CFR 30.232 20 CFR 30.807 20 CFR 30.905 20 CFR 30.907 20 CFR 30.403

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EE-1 English	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	EE-1.docx	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-2 English	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	EE-2.docx	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-3 English	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	EE-3.docx	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form	Form EE-8 and EN-8	Letter to Claimant EE-8 and EN-8	EE-8 with EN-8.docx		No		Paper Only
Form and Instruction	EE-4 English	Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act	EE-4.docx	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form	EE-9 and EN-9	Letter to Claimant EE-9 and EN-9	EE-9 and EN-9 (draft for 2015 revision)DONE.docx		No		Paper Only
Form	EE-10 and EN-10	Letter to Claimant EE-10 and EN-10	EE-10 with EN-10.docx		No		Paper Only
Form and Instruction	EE-20 and EN-20	Letter to Claimant EE-20 and EN-20	EE-20 with EN-20.docx		No		Paper Only
Form and Instruction	EE-1 Spanish	Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia	EE-1-Spa.docx	http://www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-2 Spanish	Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia	EE-2-Spa.docx	http://www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-3 Spanish	Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia	EE-3-Spa.docx	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-4 Spanish	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	EE-4-Spa.docx	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Paper Only
Form	EE-11A and EN-11A	Letter to Claimant EE-11A and EN-11A	EE-11A with EN-11A.docx		No		Paper Only
Form	EE-11B and EN-11B	Letter to Claimant EE-11B and EN-11B	EE-11B with EN-11B.docx		No		Paper Only
Form	EE-12 and EN-12	Letter to Claimant EE-12 and EN-12	EE-12 with EN-12.docx		No		Paper Only
Form	EE-16 and EN-16	Letter to Claimant EE-16 and EN-16	EE-16 with EN-16.docx		No		Paper Only
Form and Instruction	EE-17B	Physician's Certification of Medical Necessity Under the Energy Employees Occupational Illness Compensation Program Act	EE-17B.docx		Yes	No	Fillable Fileable
Form	EE-17A	Claim for Home Health Care, Nursing Home, or Assited Living Benefits Under the Energy Employees Occupational Programs Act	EE-17A.docx		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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: 55,167

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60,751	4,694	56,057
Annual IC Time Burden (Hours)	21,299	1,823	19,476
Annual IC Cost Burden (Dollars)	28,427	5,220	23,207

Documents for IC

table that charts IC Documents
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.