Energy Employees Occupational Illness Compensation Program Act Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EE-13 with EN-13 Letter to State Workers' Compensation	Form	Modified	Available
Form EE-13 with EN-13 EEOICP Forms for State Governments	Form	Modified	Repair queued
Form EE-17B Physician Certification of Medical Necessity under the EEOICPA	Form and Instruction	Modified	Available
Form EE-7 Medical requirements	Form	Modified	Available
Form EE-7-Spa Medical requirements - Spanish	Form	Modified	Available
Form EE-7-Spa EEOICP Forms for Private Sector	Form	Modified	Repair queued
Form EE-4 Affidavit in support of work history	Form and Instruction	Modified	Available
Form EE-4-Spa Affidavit in support of work history - Spanish	Form and Instruction	Modified	Available
Form EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT	Form and Instruction	Modified	Repair queued
Form EE-16 and EN-16 Letter to Claimant	Form	Modified	Available
Form EE-12 and EN-12 Letter to Claimant	Form	Modified	Available
Form EE-11B and EN-11B Letter to Claimant	Form	Modified	Available
Form EE-11A and EN-11A Letter to Claimant	Form	Modified	Available
Form 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	Form and Instruction	Modified	Repair queued
Form 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	Form and Instruction	Modified	Available
Form EE-1 Spanish Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia	Form and Instruction	Modified	Available
Form EE-20 and EN-20 Letter to Claimant	Form and Instruction	Modified	Available
Form EE_10 and EN-10 Letter to Claimant	Form	Modified	Available
Form EE-9 and EN-9 Letter to Claimant	Form	Modified	Available
Form Form EE-8 and EN-8 Letter to Claimant	Form	Modified	Repair queued
Form EE-3 English Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Repair queued
Form EE-1 English EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Repair queued
1240-0002 Supporting Statement 2.22.22.docx	Supporting Statement A	Uploaded 2022-02-22	Available
1240-0002 Supporting regulatory and statutory provisions.docx	Supplementary Document	Uploaded 2021-09-16	Repair queued
Form EE-5.pdf	Supplementary Document	Uploaded 2021-09-16	Repair queued
Supporting Regulations.pdf	Supplementary Document	Uploaded 2013-06-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
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	Letter to State Workers' Compensation
178684	EEOICP Forms for State Governments	Form	Modified
178683	EEOICP Forms for Private Sector	Form and Instruction	Modified	Physician Certification of Medical Necessity under the EEOICPA
178683	EEOICP Forms for Private Sector	Form	Modified	Medical requirements
178683	EEOICP Forms for Private Sector	Form	Modified	Medical requirements - Spanish
178683	EEOICP Forms for Private Sector	Form	Modified
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Affidavit in support of work history
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Affidavit in support of work history - Spanish
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
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: Historical Active	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
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/04/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/01/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2025	36 Months From Approved	05/31/2022
Responses	48,051	0	60,294
Time Burden (Hours)	16,374	0	20,359
Cost Burden (Dollars)	36,088	0	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

table that charts list of burden

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 English, EE-1 Spanish, EE-3 English, EE-3 Spanish, 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

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	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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