Information Collection

EEOICP Forms for Individuals or Households

IC 13934 under ICR 202004-1240-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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-11B and EN-11B EEOICP Forms for Individuals or Households	Form
EE-1 English Worker's Claim for Benefits Under the Energy Employees O EE-1 Workers Claim for Benefits under the EEOIC Program Act.pdf 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 Survivor’s Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act.pdf 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 with EN-8.docx	Form
EE-9 and EN-9 Letter to Claimant EE-9 with EN-9.doc	Form
EE_10 and EN-10 Letter to Claimant EE-10 with EN-10.docx	Form
EE-20 and EN-20 Letter to Claimant EE-20 with EN-20.doc	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 - Reclamación de beneficios de sobreviviente según la Ley del Programa de Indemnización por Enfermedades Ocupacionales 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 with EN-11A.docx	Form
EE-11B and EN-11B Letter to Claimant EE-11B with EN-11B.docx	Form
EE-12 and EN-12 Letter to Claimant EE-12 with EN-12.doc	Form
EE-16 and EN-16 Letter to Claimant EE-16 with EN-16.docx	Form
EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LI EE-17A Claim for Home Health Care Nursing Home or Assisted Living Benefits Under the EEOIC Program Act.pdf	Form and Instruction
EE-17B PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY UNDER THE EE-17B Physicians Certification of Medical Necessity Under the EEOICPA.pdf	Form and Instruction

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 30.222 20 CFR 30.111 20 CFR 30.103 20 CFR 30.102 20 CFR 30.231 20 CFR 30.415 20 CFR 30.416 20 CFR 30.214 20 CFR 30.806 20 CFR 30.221 20 CFR 30.113 20 CFR 30.101 20 CFR 30.213 20 CFR 30.417 20 CFR 30.505 20 CFR 30.100 20 CFR 30.114 20 CFR 30.206 20 CFR 30.212 20 CFR 30.620 20 CFR 30.207

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	EE-11B and EN-11B	Letter to Claimant	EE-11B with EN-11B.docx		No		Paper Only
Form	EE-12 and EN-12	Letter to Claimant	EE-12 with EN-12.doc		No		Paper Only
Form	EE-16 and EN-16	Letter to Claimant	EE-16 with EN-16.docx		No		Paper Only
Form and Instruction	EE-17A	CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT	EE-17A Claim for Home Health Care Nursing Home or Assisted Living Benefits Under the EEOIC Program Act.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-17B	PHYSICIANâS CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION	EE-17B Physicians Certification of Medical Necessity Under the EEOICPA.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-1 English	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	EE-1 Workers Claim for Benefits under the EEOIC Program Act.pdf	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 Survivorâs Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act.pdf	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 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	Form EE-8 and EN-8	Letter to Claimant	EE-8 with EN-8.docx		No		Paper Only
Form	EE-9 and EN-9	Letter to Claimant	EE-9 with EN-9.doc		No		Paper Only
Form	EE_10 and EN-10	Letter to Claimant	EE-10 with EN-10.docx		No		Paper Only
Form and Instruction	EE-20 and EN-20	Letter to Claimant	EE-20 with EN-20.doc		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 - ReclamaciÃ³n de beneficios de sobreviviente segÃºn la Ley del Programa de IndemnizaciÃ³n por Enfermedades Ocupacionales para Empleados del Sector de la EnergÃa.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 with EN-11A.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-11

FR Citation: 81 FR 25868

Number of Respondents: 54,754

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	54,754	54,754
Annual IC Time Burden (Hours)	18,171	18,171
Annual IC Cost Burden (Dollars)	29,289	29,289

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.