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
Attachment F HSRB 10-DCAS-NR01 060310 non-research.pdf	Supplementary Document	Uploaded 2016-06-27	Available
Attachment B FRN 60-day 2016-06708.pdf	Supplementary Document	Uploaded 2016-06-27	Available
Attachment H Public Comment FRN.docx	Supplementary Document	Uploaded 2016-06-27	Available
Attachment G ANWAG comments FRN.pdf	Supplementary Document	Uploaded 2016-06-27	Available
SS B.docx	Supporting Statement B	Uploaded 2016-06-27	Available
Supporting Statement A 6.20.2016.docx	Supporting Statement A	Uploaded 2016-06-27	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

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	Unchanged
180183	Form B 42 CFR Part 83.9	Form	Modified

ICR Details

OMB Control No: 0920-0639	ICR Reference No: 201606-0920-010
Status: Historical Active	Previous ICR Reference No: 201305-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0639
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: 10/05/2016
	Date Received in OIRA: 06/27/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	36 Months From Approved	10/31/2016
Responses	13	0	23
Time Burden (Hours)	41	0	51
Cost Burden (Dollars)	0	0	0

---

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. NIOSH is charged with carrying out certain responsibilities under the Energy Employees Occupational Illness Compensation Program Act of 2000 on behalf of U.S. nuclear weapons workers with cancer. One of these responsibilities is to consider petitions by classes of nuclear weapons workers to be added to the Special Exposure Cohort (SEC), a cohort of workers 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. EEOICPA authorizes HHS to designate such classes of employees for addition to the Cohort when HHS lacks information to estimate the radiation doses received by these workers with sufficient accuracy.

---

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 15722	03/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 41540	06/27/2016
Did the Agency receive public comments on this ICR? Yes

---

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
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
Authorization Form on behalf of Claimant under 42 CFR 83.7

---

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	13	23	0	-10	0	0
Annual Time Burden (Hours)	41	51	0	-10	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: Submission of 0920-0639 is an Extension of a currently approved ICR. Based on previous collection, small changes have been made to the number of Respondents and the time that could be required for completion of one of the Forms.

---

Annual Cost to Federal Government: $10,735

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

---

Common Form ICR:  No

---

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: 06/27/2016

---