Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EE-1 Claim for Consequential Illness under the EEOICPA	Form and Instruction	New	Available
Form EE-1 Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act	Form and Instruction	New	Repair queued
1240-0NEW_Supporting Statement_DEEOIC Consequential Illness Form (EE1-A)_FINAL.docx	Supporting Statement A	Uploaded 2024-05-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
267380	Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act	Form and Instruction	New	Claim for Consequential Illness under the EEOICPA
267380	Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act	Form and Instruction	New

ICR Details

OMB Control No: 1240-0063	ICR Reference No: 202405-1240-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/09/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/29/2024
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
Responses	4,850	0	0
Time Burden (Hours)	810	0	0
Cost Burden (Dollars)	1,120	0	0

---

Abstract: Form EE-1A, Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act, will be used to initiate claims for consequential illnesses under the Act. It requests information about the employee/claimant, the specific medical diagnoses that they claim as consequential illness(es), and previous awards or settlements received in connection with the claimed consequential illnesses.

---

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 11320	02/14/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 46424	05/29/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act	EE-1	Claim for Consequential Illness under the EEOICPA

---

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	4,850	0	0	4,850	0	0
Annual Time Burden (Hours)	810	0	0	810	0	0
Annual Cost Burden (Dollars)	1,120	0	0	1,120	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There are no adjustments or program changes for 1240-0NEW.

---

Annual Cost to Federal Government: $30,399

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

---

Common Form ICR:  No

---

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: 05/29/2024

---