EEOICP Forms for Individuals or Households

Energy Employees Occupational Illness Compensation Program Act Forms

OMB: 1240-0002

IC ID: 13934

Documents and Forms
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Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
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Form and Instruction
Form and Instruction
Form and Instruction
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Information Collection (IC) Details

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EEOICP Forms for Individuals or Households
 
No Modified
 
Required to Obtain or Retain Benefits
 
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

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 Workers Claim for Benefits Under the EEOICPA.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 Survivors Claim for Benefits Under the EEOICPA (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 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 Smoking History (EE-8 with EN-8).docx No   Paper Only
Form EE-9 and EN-9 Letter to Claimant Racial_Ethnic ID (EE-9 with EN-9).docx No   Paper Only
Form EE_10 and EN-10 Letter to Claimant Claim for Additional WL and or IMP (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 - Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales.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 Reclamacion de beneficios segun la Ley del Programa de Indmnizacion por Enfermedades Ocupacionales (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 Response Requested for Impairment (EE-11A with EN-11A).docx No   Paper Only
Form EE-11B and EN-11B Letter to Claimant Wage Loss Letter and Response Form (EE-11B with EN-11B).docx No   Paper Only
Form EE-12 and EN-12 Letter to Claimant Request for Update - State Workers' Comp (EE-12 with EN-12).docx No   Paper Only
Form EE-16 and EN-16 Letter to Claimant Compensation Payment Questionnaire (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 Claim for Home Health Care, Nursing Home or Assisted Living Benefits under the EEOICPA (EE-17A).docx Yes Yes Fillable Fileable Signable
Form and Instruction EE-17B PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION Physician's Certification of Medical Necessity Under the EEOICPA (EE-17B).docx Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

DOL/OWCP-11  81 FR 25868

54,754 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 54,754 0 0 0 0 54,754
Annual IC Time Burden (Hours) 18,171 0 0 0 0 18,171
Annual IC Cost Burden (Dollars) 29,289 0 0 0 0 29,289

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