Energy Employees Occupational Illness Compensation Program Act Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EE-13 Letter to State Workers' Compensation	Form	Modified	Available
Form EE-13 EEOICP Forms for State Governments	Form	Modified	Repair queued
Form EE-17B Physician Certification of Medical Necessity under the EEOICPA	Form and Instruction	Modified	Available
Form EE-7 Medical requirements	Form	Modified	Available
Form EE-7 EEOICP Forms for Private Sector	Form	Modified	Missing upstream
Form EE-4 Spanish Declaración jurada sobre historial de empleo para reclamación según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía	Form and Instruction	Modified	Available
Form EE-4 Employment History Affidavit for a Claim under the EEOICPA	Form and Instruction	Modified	Available
Form EE-4 English Employment History Affidavit for a Claim under the EEOICPA	Form and Instruction	Modified	Available
Form EE-17B Physician's Certification of Necessity Under the EEOICPA	Form and Instruction	Modified	Available
Form EE-13 Letter to State Workers Compensation Authorities	Form and Instruction	Modified	Available
Form EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT	Form and Instruction	Modified	Available
Form EE-16 and EN-16 Letter to Claimant	Form	Modified	Available
Form EE-12 Letter to Claimant	Form	Modified	Available
Form EE-20 Letter to Claimant	Form and Instruction	Modified	Available
Form EE-10 Letter to Claimant	Form	Modified	Available
Form EE-9 Letter to Claimant	Form	Modified	Available
Form Form EE-8 Letter to Claimant	Form	Modified	Available
Form EE-3 English Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction	Modified	Available
Form EE-1 English EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Repair queued
PC_202412-1240-003_050125_080243_1.pdf	Public Comments	Uploaded 2025-05-01	Repair queued
Supporting Statement for 1240-0002 4 1 25_Reponse to comment_20250506.docx	Supporting Statement A	Uploaded 2025-05-08	Repair queued
Supporting Statement for 1240-0002 4 1 25.docx	Supporting Statement A	Uploaded 2025-04-01	Repair queued
1240-0002 Supporting regulatory and statutory provisions.docx	Supplementary Document	Uploaded 2021-09-16	Repair queued
1240-0002 Supporting regulatory and statutory provisions.docx	Supplementary Document	Uploaded 2021-09-16	Repair queued
Form EE-5.pdf	Supplementary Document	Uploaded 2021-09-16	Repair queued
Form EE-5.pdf	Supplementary Document	Uploaded 2021-09-16	Repair queued
Supporting Regulations.pdf	Supplementary Document	Uploaded 2013-06-11	Repair queued
Supporting Regulations.pdf	Supplementary Document	Uploaded 2013-06-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
251537	EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)		Modified
251536	EE -5B - Supplemental Employment Evidence - DOE Contractors		Modified
251535	EE 5A - Supplemental Employment Evidence		Modified
178684	EEOICP Forms for State Governments	Form	Modified	Letter to State Workers' Compensation
178684	EEOICP Forms for State Governments	Form	Modified
178683	EEOICP Forms for Private Sector	Form and Instruction	Modified	Physician Certification of Medical Necessity under the EEOICPA
178683	EEOICP Forms for Private Sector	Form	Modified	Medical requirements
178683	EEOICP Forms for Private Sector	Form	Modified
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Declaración jurada sobre historial de empleo para reclamación según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History Affidavit for a Claim under the EEOICPA
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History Affidavit for a Claim under the EEOICPA
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Physician's Certification of Necessity Under the EEOICPA
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Letter to State Workers Compensation Authorities
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form	Modified	Letter to Claimant
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
13934	EEOICP Forms for Individuals or Households	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0002	ICR Reference No: 202412-1240-003
Status: Historical Active	Previous ICR Reference No: 202109-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Energy Employees Occupational Illness Compensation Program Act Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/09/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/01/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2028	36 Months From Approved	05/31/2025
Responses	78,317	0	48,051
Time Burden (Hours)	23,939	0	16,374
Cost Burden (Dollars)	26,522	0	36,088

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Abstract: The information collected by these forms is used by claims examiners in OWCP to determine eligibility for compensation. The information, with the medical evidence and other supporting documentation, is used to determine whether the claimant is entitled to compensation under Part B or Part E of EEOICPA, and the amount of that compensation.

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Authorizing Statute(s): US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 42 USC 7385(s) through 11 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 90072	11/14/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 14391	04/01/2025
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 - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)
EE -5B - Supplemental Employment Evidence - DOE Contractors
EE 5A - Supplemental Employment Evidence
EEOICP Forms for Individuals or Households	EE-13, EE-20 , EE-10, EE-17B, EE-3 English, EE-1 English, EE-2 English, EE-9 , Form EE-8 , EE-12 , EE-16 and EN-16, EE-17A, EE-4 English, EE-4, EE-4 Spanish	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT ,   Letter to State Workers Compensation Authorities ,   Physician's Certification of Necessity Under the EEOICPA ,   Employment History Affidavit for a Claim under the EEOICPA ,   Employment History Affidavit for a Claim under the EEOICPA ,   Declaración jurada sobre historial de empleo para reclamación según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía
EEOICP Forms for Private Sector	EE-7, EE-17B	Medical requirements ,   Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments	EE-13	Letter to State Workers' Compensation

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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	78,317	48,051	0	30,266	0	0
Annual Time Burden (Hours)	23,939	16,374	0	7,565	0	0
Annual Cost Burden (Dollars)	26,522	36,088	0	-9,566	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden hours increased from 16,374 to 23,939. There is an overall adjustment of +7,565 in burden hours due to an increase in the number of claims being adjudicated (+ 30,266 more responses). However, there has been a decrease in the operation and maintenance costs of -$9,566, due to the electronic submission of many responses. Responses increased from 48,051 to 78,317. However, there has been a decrease in the operation and maintenance costs from $36,088 to $26,523, due to the electronic submission of many responses.

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Annual Cost to Federal Government: $541,228

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: 04/01/2025

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