OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Energy Employees Occupational Illness Compensation Program Act Forms

ICR 202004-1240-002 · OMB 1240-0002 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form EE-13 with EN-13 EEOICP Forms for State Governments Form Unchanged Available
Form EE-7 English EEOICP Forms for Private Sector Form and Instruction Unchanged Available
Form EE-11B and EN-11B EEOICP Forms for Individuals or Households Form Modified Available
Justification EE-1 EE-1 SPA EE-2 EE-2 SPA EE-17 and EE-17B.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-04-08 Repair queued
Justification - EE8 with EN 8EE-8 EN-8, EE-9 EN-9, EE-10 EN-10, EE-11A EN-11A, EE-11B EN-11B, EE-12 EN-12 and EN-16 EN16.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-02-24 Available
EE-16 with EN-16.docx Supplementary Document Uploaded 2020-02-24 Available
EE-12 with EN-12.docx Supplementary Document Uploaded 2020-02-24 Available
EE-11B with EN-11B.pdf Supplementary Document Uploaded 2020-02-24 Available
EE-11 with EN-11.pdf Supplementary Document Uploaded 2020-02-24 Available
EE-10 with EN-10.pdf Supplementary Document Uploaded 2020-02-24 Available
EE-9 with EN-9.docx Supplementary Document Uploaded 2020-02-24 Available
EE-8 with EN-8.docx Supplementary Document Uploaded 2020-02-24 Repair queued
Supporting Regulations.pdf Supplementary Document Uploaded 2013-06-11 Available
Supporting statement 1240-0002 2019 DEEOIC RuleMaking.docx Supporting Statement A Uploaded 2019-02-01 Available
IC Document Collections
IC IDCollectionTypeStatusForm
178684 EEOICP Forms for State Governments Form Unchanged
178683 EEOICP Forms for Private Sector Form and Instruction Unchanged
13934 EEOICP Forms for Individuals or Households Form Modified
ICR Details
1240-0002 202004-1240-002
Historical Active 202002-1240-019
DOL/OWCP
Energy Employees Occupational Illness Compensation Program Act Forms
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/13/2020
Retrieve Notice of Action (NOA) 04/12/2020
  Inventory as of this Action Requested Previously Approved
03/31/2022 03/31/2022 03/31/2022
60,294 0 60,294
20,359 0 20,359
32,334 0 32,334
PO Box Address change for the EE-17A, EE-2-SPA, EE-2, EE-17B, EE-1 and EE-1-SPA only. The Energy Employee forms are required to determine a claimant's eligibility for compensation under the Energy Employee Occupation Illness Compensation Program Act and are required to enable eligible claimants to receive benefits.
US Code: 42 USC 7385(s) through 11 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
  
None
1240-AA08 Final or interim final rulemaking 84 FR 3026 02/08/2019
  80 FR 72296 11/18/2015
80 FR 72296 11/18/2015
Yes
3
IC Title Form No. Form Name
EEOICP Forms for State Governments EE-13 with EN-13 Letter to State Workers' Compensation
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 Individuals or Households EE-20 and EN-20, EE-4 Spanish, EE_10 and EN-10, 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, EE-17B, EE-17A Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT ,   PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION ,   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 ,   Letter to Claimant
  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 60,294 60,294 0 0 0 0
Annual Time Burden (Hours) 20,359 20,359 0 0 0 0
Annual Cost Burden (Dollars) 32,334 32,334 0 0 0 0
No
No
$318,499
No
    Yes
    Yes
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.
04/12/2020