Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EE-32 Home Health Care Authorization Request	Form and Instruction	Modified	Available
Form EE-32 EE-32 (Home Health Care Authorization Request)	Form and Instruction	Modified	Repair queued
Form EE-30 Transplant Authorization Request	Form and Instruction	Modified	Available
Form EE-30 EE-30 (Transplant Authorization Request)	Form and Instruction	Modified	Repair queued
Form EE-28 Transportation Authorization Request	Form and Instruction	Modified	Available
Form EE-28 EE-28 (Transportation Authorization Request)	Form and Instruction	Modified	Repair queued
Form EE-26 Rehabiltative Therapies Authorization Request	Form and Instruction	Modified	Available
Form EE-26 EE-26 (Rehabilitative Therapies Authorization Request)	Form and Instruction	Modified	Repair queued
Form EE-24 Durable Medical Equipment Authorization Request	Form and Instruction	Modified	Available
Form EE-24 EE-24 (Durable Medical Equipment Authorization)	Form and Instruction	Modified	Repair queued
Form EE-22 General Medical Authorization Request	Form and Instruction	Modified	Available
Form EE-22 EE-22 (General Medical Authorization Request)	Form and Instruction	Modified	Repair queued
Supporting Statement 1240-0060_Renewal_2024_FINAL_05 2024.docx	Supporting Statement A	Uploaded 2024-05-22	Repair queued
20 CFR Part 30.pdf	Supplementary Document	Uploaded 2020-09-24	Repair queued
42 USC 7384 et seq.pdf	Supplementary Document	Uploaded 2020-09-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243779	EE-32 (Home Health Care Authorization Request)	Form and Instruction	Modified	Home Health Care Authorization Request
243779	EE-32 (Home Health Care Authorization Request)	Form and Instruction	Modified
243778	EE-30 (Transplant Authorization Request)	Form and Instruction	Modified	Transplant Authorization Request
243778	EE-30 (Transplant Authorization Request)	Form and Instruction	Modified
243777	EE-28 (Transportation Authorization Request)	Form and Instruction	Modified	Transportation Authorization Request
243777	EE-28 (Transportation Authorization Request)	Form and Instruction	Modified
243776	EE-26 (Rehabilitative Therapies Authorization Request)	Form and Instruction	Modified	Rehabiltative Therapies Authorization Request
243776	EE-26 (Rehabilitative Therapies Authorization Request)	Form and Instruction	Modified
243775	EE-24 (Durable Medical Equipment Authorization)	Form and Instruction	Modified	Durable Medical Equipment Authorization Request
243775	EE-24 (Durable Medical Equipment Authorization)	Form and Instruction	Modified
243774	EE-22 (General Medical Authorization Request)	Form and Instruction	Modified	General Medical Authorization Request
243774	EE-22 (General Medical Authorization Request)	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0060	ICR Reference No: 202404-1240-008
Status: Historical Active	Previous ICR Reference No: 202211-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request 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: 07/02/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/30/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	98,020	0	66,770
Time Burden (Hours)	16,337	0	11,129
Cost Burden (Dollars)	0	0	0

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Abstract: The Office of Workers’ Compensation Programs (OWCP) is the primary agency responsible for administration of the Energy Employees Occupational Illness Compensation Program Act of 2000, as amended (EEOICPA), 42 U.S.C. § 7384 et seq. EEOICPA provides for the payment of compensation to covered employees and, where applicable, survivors of deceased employees, who sustained either an “occupational illness” or a “covered illness” in the performance of duty for the Department of Energy and certain of its contractors and subcontractors. One element of the compensation provided to covered employees is medical benefits for the treatment of their occupational or covered illnesses that are accepted as compensable. OWCP contracts with a private sector bill processing agent that handles many of the tasks associated with paying bills for medical treatment provided to covered employees under EEOICPA. This bill processing agent uses an automated system that matches incoming bills with the authorized medical treatment of covered employees before it issues payments, and a provider of medical treatment, supplies or services to covered employees must provide the bill processing agent with information necessary for creation of an authorization within the agent’s automated system before a bill can be paid. The collection of this information is authorized by 20 CFR 30.400(a) and (c), 30.403, 30.404(b) and 30.700. The information collected by these forms will be used by both OWCP and its bill processing agent in connection with the automated payment of bills submitted by providers of medical treatment, supplies or services. The information submitted, along with other supporting documentation, is used to determine the correct amount to be paid to a provider of medical treatment, supplies or services to beneficiaries under EEOICPA.

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Authorizing Statute(s): 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:
	89 FR 9868	02/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 46912	05/30/2024
Did the Agency receive public comments on this ICR? No

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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-22 (General Medical Authorization Request)	EE-22	General Medical Authorization Request
EE-24 (Durable Medical Equipment Authorization)	EE-24	Durable Medical Equipment Authorization Request
EE-26 (Rehabilitative Therapies Authorization Request)	EE-26	Rehabiltative Therapies Authorization Request
EE-28 (Transportation Authorization Request)	EE-28	Transportation Authorization Request
EE-30 (Transplant Authorization Request)	EE-30	Transplant Authorization Request
EE-32 (Home Health Care Authorization Request)	EE-32	Home Health Care Authorization Request

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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	98,020	66,770	0	0	31,250	0
Annual Time Burden (Hours)	16,337	11,129	0	0	5,208	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: $3,466,352

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: 05/30/2024

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