Information Collection

EEOICP Forms for Private Sector

IC 178683 under ICR 202603-1240-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EE-7 Medical requirements EEOICP Forms for Private Sector	Form
Form EE-17B Physician Certification of Medical Necessity under the EEOICPA EEOICP Forms for Private Sector	Form and Instruction
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

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: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.415 through 30.417 20 CFR 30.215 20 CFR 30.106 20 CFR 30.103 20 CFR 30.905 20 CFR 30.232 (a) and (b) 20 CFR 30.207 20 CFR 30.907 20 CFR 30.222

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	EE-7				Yes	No	Printable Only
Form and Instruction	EE-17B				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: 3,500

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	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	1,185	1,185

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].