OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Energy Employees Occupational Illness Compensation Program Act Forms

ICR 201510-1240-002 · OMB 1240-0002 · Historical Inactive

Forms and Documents
DocumentTypeStatusAvailability
Form EE-13 and EN-13 EEOICP Forms for State Governments Form Modified Repair queued
Form EE-7 English EEOICP Forms for Private Sector Form and Instruction Modified Repair queued
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction Modified Repair queued
Supporting Regulations.pdf Supplementary Document Uploaded 2013-06-11 Available
Supporting statement for REVISION to 1240-0002 Rulemaking.docx Supporting Statement A Uploaded 2015-10-02 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
178684 EEOICP Forms for State Governments Form Modified
178683 EEOICP Forms for Private Sector Form and Instruction Modified
13934 EEOICP Forms for Individuals or Households Form and Instruction Modified
ICR Details
1240-0002 201510-1240-002
Historical Inactive 201304-1240-001
DOL/OWCP
Energy Employees Occupational Illness Compensation Program Act Forms
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 01/19/2016
Retrieve Notice of Action (NOA) 11/18/2015
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved 03/31/2017
66,020 0 66,020
23,190 0 23,190
28,089 0 28,089
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
1240-AA08 Proposed rulemaking 80 FR 72296 11/18/2015
  80 FR 72269 11/18/2015
No
3
IC Title Form No. Form Name
EEOICP Forms for Private Sector 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 State Governments EE-13 and EN-13 EEOICP forms for State Workers' Compensation Agency
EEOICP Forms for Individuals or Households EE-17B, EE-17A, 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, EE-11A and EN-11A, EE-11B and EN-11B, EE-12 and EN-12, EE-16 and EN-16 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 ,   Letter to Claimant EE-8 and EN-8 ,   Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant EE-9 and EN-9 ,   Letter to Claimant EE-10 and EN-10 ,   Letter to Claimant EE-20 and EN-20 ,   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 ,   Letter to Claimant EE-11A and EN-11A ,   Letter to Claimant EE-11B and EN-11B ,   Letter to Claimant EE-12 and EN-12 ,   Letter to Claimant EE-16 and EN-16 ,   Physician's Certification of Medical Necessity Under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Home Health Care, Nursing Home, or Assited Living Benefits Under the Energy Employees Occupational Programs Act
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
There is an overall adjustment of +556 in burden hours due to a shift in the type of claims being adjudicated to those that require the submission of more information, and the new EE-17A and EE-17B; this increase has been offset by a reduction in the amount of burden hours for other requirements in Control No. 1240-0002. There has also been an increase in the operation and maintenance costs of +$3,414, due to new responses and increased mailing costs, from $28,089 to $31,503.
$329,173
No
No
No
No
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.
11/18/2015