Information Collection

EEOICP Forms for Private Sector

IC 178683 under ICR 202109-1240-002 · OMB 1240-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0002 can be found here:

2026-05-28 - No material or nonsubstantive change to a currently approved collection
2026-03-12 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.