OMB control number
Energy Employees Occupational Illness Compensation Program Act Forms
OMB 1240-0002 · DOL/OWCP.
OMB 1240-0002
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.
The latest form for Energy Employees Occupational Illness Compensation Program Act Forms expires 2028-05-31 and is listed under ICR 202603-1240-001.
Latest Forms, Documents, and Supporting Material
Form EE-13 Letter to State Workers' Compensation
Form EE-17B Physician Certification of Medical Necessity under the EEOICPA
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)All Historical Document Collections
OMB Details
EEOICP Forms for Individuals or Households
Federal Enterprise Architecture: Income Security - General Retirement and Disability
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form EE-17B | Physician's Certification of Necessity Under the EEOICPA | eclaimant.dol.gov | Form and instruction |
| 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 | eclaimant.dol.gov | Form and instruction |
| Form EE-4 | Employment History Affidavit for a Claim under the EEOICPA | www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms | Form and instruction |
| Form EE-4 English | Employment History Affidavit for a Claim under the EEOICPA | www.dol.gov/ agencies/owcp/energy/regs/compliance/claim_forms | Form and instruction |
| Form EE-17A | CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT | Paper Only | Form and instruction |
| Form EE-16 and EN-16 | Letter to Claimant | Paper Only | Form |
| Form EE-12 | Letter to Claimant | Paper Only | Form |
| Form Form EE-8 | Letter to Claimant | Paper Only | Form |
| Form EE-9 | Letter to Claimant | Paper Only | Form |
| Form EE-2 English | Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act | www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms | Form and instruction |
| Form EE-1 English | Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act | www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms | Form and instruction |
| Form EE-3 English | Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act | www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms | Form and instruction |
| Form EE-10 | Letter to Claimant | Paper Only | Form |
| Form EE-20 | Letter to Claimant | Paper Only | Form and instruction |
| Form EE-13 | Letter to State Workers Compensation Authorities | Paper Only | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.