OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Energy Employees Occupational Illness Compensation Program Act Forms (Various)

ICR 201004-1240-002 · OMB 1240-0002 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form EE-7 English EEOICP Forms for Business or other for profits Form and Instruction Modified Available
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction Modified Repair queued
SS for revision to 1240-0002 (05-12-2010) (2).doc Supporting Statement A Uploaded 2010-05-13 Available
Supporting regulations 1240-0002.doc Supplementary Document Uploaded 2010-04-19 Available
IC Document Collections
IC IDCollectionTypeStatusForm
178684 EEOICP Forms for Federal Government Other-EEOICP forms for State Government Modified
178683 EEOICP Forms for Business or other for profits Form and Instruction Modified
13934 EEOICP Forms for Individuals or Households Form and Instruction Modified
ICR Details
1240-0002 201004-1240-002
Historical Active 201003-1240-002
DOL/OWCP
Energy Employees Occupational Illness Compensation Program Act Forms (Various)
Revision of a currently approved collection   No
Regular
Approved without change 10/08/2010
Retrieve Notice of Action (NOA) 08/09/2010
  Inventory as of this Action Requested Previously Approved
10/31/2013 36 Months From Approved 10/31/2010
36,966 0 79,062
17,477 0 35,447
2,317 0 4,629
The EE forms are required to determine a claimant's eligibility for compensation under the EEOICPA and are required to enable eligible claimants to receive benefits.
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
  
None
Not associated with rulemaking
  75 FR 10504 03/08/2010
75 FR 47029 08/04/2010
No
3
IC Title Form No. Form Name
EEOICP Forms for Business or other for profits EE-7 English, EE-7 Spanish Medial Requirements under rhe Energy Employees Occupational Illness Compensation Program Act ,   Requisitos medicos segun la Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de la Energia
EEOICP Forms for Federal Government
EEOICP Forms for Individuals or Households EE_10 and EN-10, EE-20 and EN-20, EE-4 Spanish, EE-2 Spanish, EE-1 Spanish, EE-3 English, EE-3 Spanish, EE-1 English, EE-2 English, EE-4 English, EE-9 and EN-9, Form EE-8 and EN-8 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 ,   Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia ,   Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia ,   Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia ,   Declaracion jurada sobre historial de empleo para reclamacion sequin la Ley del Programa de Indemnizacioon por Enfermedades Ocupacionales para Empleados del Sector de la Energia
  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 36,966 79,062 0 -42,096 0 0
Annual Time Burden (Hours) 17,477 35,447 0 -17,970 0 0
Annual Cost Burden (Dollars) 2,317 4,629 0 -2,312 0 0
No
Yes
Miscellaneous Actions
There is an overall adjustment of -13,718 in burden hours due to a decrease in the number of claimants from prior years. There has also been an increase in the operation and maintenance cost of +$18,152 since mailing costs have increased from $4,629 to 22, 781.
$396,504
No
No
No
Uncollected
No
Uncollected
Sheldon Turley 202-693-5337 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/09/2010