EEOICP Forms for Private Sector

Energy Employees Occupational Illness Compensation Program Act Forms

Documents and Forms

Document Name Document Type
Form EE-7-Spa EEOICP Forms for Private Sector Form
EE-7-Spa Medical requirements - Spanish Draft EE-7-Spa.docx Form
EE-7-Spa Medical requirements - Spanish Draft EE-7-Spa.docx Form
EE-7 Medical requirements Draft EE-7.docx Form
EE-7 Medical requirements Draft EE-7.docx Form
EE-17B Physician Certification of Medical Necessity under the E EE-17B.docx Form and Instruction
EE-17B Physician Certification of Medical Necessity under the E EE-17B.docx Form and Instruction

Information Collection (IC) Details

IC Title:	EEOICP Forms for Private Sector	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 30.106 20 CFR 30.215 20 CFR 30.103 20 CFR 30.415 through 30.417 20 CFR 30.207 20 CFR 30.905 20 CFR 30.232 (a) and (b) 20 CFR 30.907

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	EE-7-Spa	Medical requirements - Spanish	Draft EE-7-Spa.docx	Yes	No	Printable Only
Form	EE-7	Medical requirements	Draft EE-7.docx	Yes	No	Printable Only
Form and Instruction	EE-17B	Physician Certification of Medical Necessity under the EEOICPA	EE-17B.docx	Yes	Yes	Fillable Fileable Signable

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: 6,479	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,479	990	5,489
Annual IC Time Burden (Hours)	2,252	880	1,372
Annual IC Cost Burden (Dollars)	5,248	2,229	3,019

Documents for IC

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.