Information Collection

Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act

IC 267380 under ICR 202405-1240-001 · OMB 1240-0063.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EE-1 Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act	Form and Instruction
Form EE-1 Claim for Consequential Illness under the EEOICPA Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act	Form and Instruction
EE-1 Claim for Consequential Illness under the EEOICPA Claim for Consequential Illness under the EEOICPA (EE-1)_FINAL.docx www.dol.gov/agencies/owcp/energy/regs/compliance/claims_forms	Form and Instruction
EE-1 Claim for Consequential Illness under the EEOICPA Claim for Consequential Illness under the EEOICPA (EE-1)_FINAL.docx www.dol.gov/agencies/owcp/energy/regs/compliance/claims_forms	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.103 20 CFR 30.505 20 CFR 30.620 20 CFR 30.100

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EE-1			https://www.dol.gov/agencies/owcp/energy/regs/compliance/claims_forms	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-11

FR Citation: 81 FR 84621

Number of Respondents: 2,425

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,850	4,850
Annual IC Time Burden (Hours)	810	810
Annual IC Cost Burden (Dollars)	1,120	1,120

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.

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