Information Collection

EEOICP Forms for Individuals or Households

IC 13934 under ICR 201004-1240-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2026-03-12 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction
EE-1 English Worker's Claim for Benefits Under the Energy Employees O EE-1 (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Form and Instruction
EE-2 English Survivor's Claim for Benefits Under the Energy Employees EE-2 (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Form and Instruction
EE-3 English Employment History for a Claim Under The Energy Employee EE-3 (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Form and Instruction
EE-4 English Employment History Affidavit for a Claim Under the Energ EE-4 (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Form and Instruction
Form EE-8 and EN-8 Letter to Claimant EE-8 and EN-8 (2nd final draft for 2010).doc Form
EE-9 and EN-9 Letter to Claimant EE-9 and EN-9 (2nd final draft for 2010).doc Form
EE_10 and EN-10 Letter to Claimant EE-10 and EN-10 (2nd final draft for 2010).doc Form
EE-20 and EN-20 Letter to Claimant EE-20 and EN-20 (2nd final draft for 2010).doc Form and Instruction
EE-1 Spanish Reclamacion de beneficios segun la Ley del Programa de I EE-1-Spa (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm Form and Instruction
EE-2 Spanish Reclaamacion de beneficios de sobreviviente segun las Le EE-2-Spa (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm Form and Instruction
EE-3 Spanish Historial de empleo para reclamacion segun la Ley del Pr EE-3-Spa (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Form and Instruction
EE-4 Spanish Declaracion jurada sobre historial de empleo para reclam EE-4-Spa (2nd final draft for 2010).doc www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EEOICP Forms for Individuals or Households	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.214 20 CFR 30.222 20 CFR 30.231 20 CFR 30.415 20 CFR 30.416 20 CFR 30.101 20 CFR 30.103 20 CFR 30.102 20 CFR 30.111 20 CFR 30.221 20 CFR 30.113 20 CFR 30.100 20 CFR 30.114 20 CFR 30.206 20 CFR 30.212 20 CFR 30.213 20 CFR 30.417 20 CFR 30.505 20 CFR 30.620 20 CFR 30.207 20 CFR 30.806

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EE-1 English	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	EE-1 (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-2 English	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	EE-2 (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-3 English	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	EE-3 (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-4 English	Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act	EE-4 (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form	Form EE-8 and EN-8	Letter to Claimant	EE-8 and EN-8 (2nd final draft for 2010).doc		No		Paper Only
Form	EE-9 and EN-9	Letter to Claimant	EE-9 and EN-9 (2nd final draft for 2010).doc		No		Paper Only
Form	EE_10 and EN-10	Letter to Claimant	EE-10 and EN-10 (2nd final draft for 2010).doc		No		Paper Only
Form and Instruction	EE-20 and EN-20	Letter to Claimant	EE-20 and EN-20 (2nd final draft for 2010).doc		No		Paper Only
Form and Instruction	EE-1 Spanish	Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia	EE-1-Spa (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-2 Spanish	Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia	EE-2-Spa (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/complaince/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-3 Spanish	Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia	EE-3-Spa (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-4 Spanish	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	EE-4-Spa (2nd final draft for 2010).doc	http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA 49	FR Citation: 67 FR 16891

Number of Respondents: 29,211	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	29,211	-29,138	58,349
Annual IC Time Burden (Hours)	14,688	-14,652	29,340
Annual IC Cost Burden (Dollars)	2,317	-2,312	4,629

Documents for IC

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.