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
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Information Collection (IC) Details

View Information Collection (IC)

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 EE-1.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 Survivor’s Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act (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 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 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.docx 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.docx 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 Reclamación de beneficios según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía (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.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 Reclamación de beneficios según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía (EE-3-Spa).docx http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Yes Yes Fillable Fileable Signable
Form EE-11A and EN-11A Letter to Claimant EE-11A with EN-11A.docx No   Paper Only
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.docx 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.docx Yes Yes Fillable Fileable Signable
Form and Instruction EE-4-Spa Affidavit in support of work history - Spanish Draft EE-4-Spa.docx Yes No Fillable Printable
Form and Instruction EE-4 Affidavit in support of work history Draft EE-4.docx Yes No Fillable Printable

Income Security General Retirement and Disability

DOL/OWCP-11  81 FR 25868

38,023 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 38,023 0 0 -16,731 0 54,754
Annual IC Time Burden (Hours) 11,626 0 0 -6,545 0 18,171
Annual IC Cost Burden (Dollars) 30,799 0 0 1,510 0 29,289

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