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

Latest forms, documents, and information collections
Document	Type
Form EE-13 Letter to State Workers' Compensation	Form
Form EE-17B Physician Certification of Medical Necessity under the EEOICPA	Form and Instruction
Form EE-7 Medical requirements	Form
Form EE-2 (SPA) Reclamación de beneficios de sobreviviente según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía	Form and Instruction
Form EE-1 (SPA) Reclamación de beneficios según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía	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	Form and Instruction
Form EE-4 Employment History Affidavit for a Claim under the EEOICPA	Form and Instruction
Form EE-4 English Employment History Affidavit for a Claim under the EEOICPA	Form and Instruction
Form EE-17B Physician's Certification of Necessity Under the EEOICPA	Form and Instruction
Form EE-13 Letter to State Workers Compensation Authorities	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	Form and Instruction
Form EE-16 and EN-16 Letter to Claimant	Form
Form EE-12 Letter to Claimant	Form
Form EE-20 Letter to Claimant	Form and Instruction
Form EE-10 Letter to Claimant	Form
Form EE-9 Letter to Claimant	Form
Form Form EE-8 Letter to Claimant	Form
Form EE-3 English Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	Form and Instruction
Form EE-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction
Form EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form and Instruction
Justification for 1240-0002 Form EE-1 and Form EE-2 - Spanish Version.docx	Justification for No Material/Nonsubstantive Change
Form EE-2 Spanish-RECA Question Change 5.11.26.docx	Supplementary Document
Form EE-1 Spanish-RECA Question Change 05-2026.docx	Supplementary Document
Supporting Statement for 1240-0002 4 1 25_Reponse to comment_20250506.docx	Supporting Statement A
1240-0002 Supporting regulatory and statutory provisions.docx	Supplementary Document
Form EE-5.pdf	Supplementary Document
Supporting Regulations.pdf	Supplementary Document
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)	Information collection
EE -5B - Supplemental Employment Evidence - DOE Contractors	Information collection
EE 5A - Supplemental Employment Evidence	Information collection
EEOICP Forms for State Governments	Form
EEOICP Forms for Private Sector	Form and Instruction
EEOICP Forms for Private Sector	Form
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form
EEOICP Forms for Individuals or Households	Form
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form
EEOICP Forms for Individuals or Households	Form
EEOICP Forms for Individuals or Households	Form
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction
EEOICP Forms for Individuals or Households	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202605-1240-003	No material or nonsubstantive change to a currently approved collection	2026-05-28
202603-1240-001	No material or nonsubstantive change to a currently approved collection	2026-03-12	Approved without change
202412-1240-003	Revision of a currently approved collection	2025-04-01
202109-1240-002	Extension without change of a currently approved collection	2022-03-01	Approved with change
202008-1240-064	No material or nonsubstantive change to a currently approved collection	2020-10-20	Approved without change
202004-1240-002	No material or nonsubstantive change to a currently approved collection	2020-04-12	Approved without change
202002-1240-019	No material or nonsubstantive change to a currently approved collection	2020-02-25	Approved without change
201901-1240-001	Revision of a currently approved collection	2019-02-09	Approved without change
201610-1240-003	Revision of a currently approved collection	2016-12-30	Approved without change
201510-1240-002	Revision of a currently approved collection	2015-11-18	Comment filed on proposed rule and continue
201304-1240-001	Revision of a currently approved collection	2013-10-29	Approved without change
201004-1240-002	Revision of a currently approved collection	2010-08-09	Approved without change
201003-1240-002	Revision of a currently approved collection	2010-03-12	Approved without change

OMB Details

EEOICP Forms for Individuals or Households

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Information collection instruments
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.