Information Collection

EEOICP Forms for State Governments

IC 178684 under ICR 202002-1240-019 · OMB 1240-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0002 can be found here:

Documents and Forms

Document Name Document Type
Form EE-13 with EN-13 EEOICP Forms for State Governments Form
EE-13 with EN-13 Letter to State Workers' Compensation EE-13 with EN-13.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EEOICP Forms for State Governments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	EE-13 with EN-13	Letter to State Workers' Compensation	EE-13 with EN-13.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-11	FR Citation: 81 FR 25868

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	816	816
Annual IC Cost Burden (Dollars)	26	26

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.