Energy Employees Occupational Illness Compensation Program Act Forms

Forms and Documents

Document Name	Status
Form EE-13 with EN-13 EEOICP Forms for State Governments Form	Modified
Form EE-7-Spa EEOICP Forms for Private Sector Form	Modified
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction	Modified
1240-0002 Supporting Statement 2.22.22.docx Supporting Statement A	2022-02-22
1240-0002 Supporting regulatory and statutory provisions.docx Supplementary Document	2021-09-16
Form EE-5.pdf Supplementary Document	2021-09-16
Supporting Regulations.pdf Supplementary Document	2013-06-11

IC Document Collections

IC ID	Document Title	Status
251537	EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)	New
251536	EE -5B - Supplemental Employment Evidence - DOE Contractors	New
251535	EE 5A - Supplemental Employment Evidence	New
178684	EEOICP Forms for State Governments Form	Modified
178683	EEOICP Forms for Private Sector Form	Modified
13934	EEOICP Forms for Individuals or Households Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0002	ICR Reference No: 202109-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202008-1240-064
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Energy Employees Occupational Illness Compensation Program Act Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/01/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2022
Responses	48,051	60,294
Time Burden (Hours)	16,374	20,359
Cost Burden (Dollars)	36,088	32,334

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Abstract: The Energy Employee forms are required to determine a claimant's eligibility for compensation under the Energy Employee Occupation Illness Compensation Program Act and are required to enable eligible claimants to receive benefits.

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Authorizing Statute(s): US Code: 42 USC 7385(s) through 11 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 42 USC 7384 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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 56986	10/13/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11482	03/01/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)
EE -5B - Supplemental Employment Evidence - DOE Contractors
EE 5A - Supplemental Employment Evidence
EEOICP Forms for Individuals or Households	EE-4-Spa, EE-4, EE-20 and EN-20, EE_10 and EN-10, EE-2 Spanish, EE-1 Spanish, EE-3 English, EE-3 Spanish, EE-1 English, EE-2 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, EE-17A	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 ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   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 ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT ,   Affidavit in support of work history - Spanish ,   Affidavit in support of work history
EEOICP Forms for Private Sector	EE-7-Spa, EE-7, EE-17B	Medical requirements - Spanish ,   Medical requirements ,   Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments	EE-13 with EN-13	Letter to State Workers' Compensation

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ICR Summary of Burden

	Total Request	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	48,051	60,294	0	0	-12,243	0
Annual Time Burden (Hours)	16,374	20,359	0	0	-3,985	0
Annual Cost Burden (Dollars)	36,088	32,334	0	0	3,754	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $272,880

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 03/01/2022

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