OMB control number

[NIOSH] EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

OMB 0920-0639 · HHS/CDC.

OMB 0920-0639

The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384-7385 [1994, supp. 2001], established a compensation program to provide a lump sum payment of $150,000 and medical benefits as compensation to covered employees suffering from designated illnesses incurred as a result of their exposure to radiation, beryllium, or silica while in the performance of duty for the Department of Energy and certain of its vendors, contractors and subcontractors. NIOSH is charged with carrying out certain responsibilities under the Energy Employees Occupational Illness Compensation Program Act of 2000 on behalf of U.S. nuclear weapons workers with cancer. One of these responsibilities is to consider petitions by classes of nuclear weapons workers to be added to the Special Exposure Cohort (SEC), a cohort of workers whose claims for cancer under EEOICPA can be adjudicated without demonstrating that their cancer was “at least as likely as not” caused by radiation doses they incurred in the performance of duty. EEOICPA authorizes HHS to designate such classes of employees for addition to the Cohort when HHS lacks information to estimate the radiation doses received by these workers with sufficient accuracy. This Extension will serve to allow this information collection to continue for an additional three years.

The latest form for [NIOSH] EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8) expires 2029-01-31 and is listed under ICR 202511-0920-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 0920-0639 Special Exposure Cohort Petition — Form A_DEC2025Form and Instruction
Special Exposure Cohort Petition - Form AForm and Instruction
Form A: Special Exposure Cohort Petition 42 CFR 83.9Form and Instruction
Form 0920-0639 Special Exposure Cohort Petitioner Authorization Form_DEC2025Form and Instruction
Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Energy Employees for Addition to the Special Exposure CohortForm and Instruction
Authorization Form on behalf of Claimant under 42 CFR 83.7Form and Instruction
Form 0920-0639 Special Exposure Cohort Petition — Form B_DEC2025Form and Instruction
Special Exposure Cohort Petition-Form BForm and Instruction
Attachment B_60day FRN.pdfSupplementary Document
Supporting Statement B 2025 Final.docxSupporting Statement B
Supporting Statement A 2025 Final.docxSupporting Statement A
Supporting Statement A 2025 Final.docxSupporting Statement A
Public Comment 26SEP2025.pngPublic Comments
Attachment F HSRB NR Determination 2022_12_01.pdfSupplementary Document
Attachment F HSRB NR Determination 2022_12_01.pdf Supplementary Document
Attachment B 60-day FRN 2022_08_03.pdfSupplementary Document
Attachment B 60-day FRN 2022_08_03.pdf Supplementary Document
Attachment A EEOICPA.pdfSupplementary Document
Attachment A EEOICPA.pdf Supplementary Document
Form A: Special Exposure Cohort Petition 42 CFR 83.9 Form and Instruction
Form A: Special Exposure Cohort Petition 42 CFR 83.9 Form and Instruction
Form A: Special Exposure Cohort Petition 42 CFR 83.9 Form and Instruction
Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Petitioner Appealing Final Decision under 42 CFR 83.18 Other-Example Request for Review
Petitioner Submission Format other than Form B 42 CFR 83.9 Instruction
Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 Form and Instruction
Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 Form and Instruction
Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 Form and Instruction

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Form A: Special Exposure Cohort Petition 42 CFR 83.9

Federal Enterprise Architecture: Income Security - Survivor Compensation

Information collection instruments
FormNameElectronic accessType
Form n/aSpecial Exposure Cohort Petition - Form AFillable FileableForm and instruction
Form 0920-0639Special Exposure Cohort Petition — Form A_DEC2025N/AForm and instruction

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