OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Energy Employees Occupational Illness Compensation Program Act Forms

ICR 202109-1240-002 · OMB 1240-0002 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form EE-13 with EN-13 EEOICP Forms for State Governments Form Modified Missing upstream
Form EE-7-Spa EEOICP Forms for Private Sector Form Modified Repair queued
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction Modified Repair queued
1240-0002 Supporting Statement 2.22.22.docx Supporting Statement A Uploaded 2022-02-22 Repair queued
1240-0002 Supporting regulatory and statutory provisions.docx Supplementary Document Uploaded 2021-09-16 Repair queued
Form EE-5.pdf Supplementary Document Uploaded 2021-09-16 Missing upstream
Supporting Regulations.pdf Supplementary Document Uploaded 2013-06-11 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
251537 EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E) New
251536 EE -5B - Supplemental Employment Evidence - DOE Contractors New
251535 EE 5A - Supplemental Employment Evidence New
178684 EEOICP Forms for State Governments Form Modified
178683 EEOICP Forms for Private Sector Form Modified
13934 EEOICP Forms for Individuals or Households Form and Instruction Modified
ICR Details
1240-0002 202109-1240-002
Historical Active 202008-1240-064
DOL/OWCP
Energy Employees Occupational Illness Compensation Program Act Forms
Extension without change of a currently approved collection   No
Regular
Approved with change 05/04/2022
Retrieve Notice of Action (NOA) 03/01/2022
  Inventory as of this Action Requested Previously Approved
05/31/2025 36 Months From Approved 05/31/2022
48,051 0 60,294
16,374 0 20,359
36,088 0 32,334
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
Not associated with rulemaking
  86 FR 56986 10/13/2021
87 FR 11482 03/01/2022
Yes
6
IC Title Form No. Form Name
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)
EE -5B - Supplemental Employment Evidence - DOE Contractors
EE 5A - Supplemental Employment Evidence
EEOICP Forms for Individuals or Households EE-4-Spa, EE-4, EE-20 and EN-20, EE_10 and EN-10, EE-2 Spanish, EE-1 English, EE-1 Spanish, EE-3 English, EE-3 Spanish, EE-2 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-17A 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 ,   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 ,   Letter to Claimant ,   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 ,   Affidavit in support of work history - Spanish ,   Affidavit in support of work history
EEOICP Forms for Private Sector EE-7-Spa, EE-7, EE-17B Medical requirements - Spanish ,   Medical requirements ,   Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments EE-13 with EN-13 Letter to State Workers' Compensation
  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 48,051 60,294 0 0 -12,243 0
Annual Time Burden (Hours) 16,374 20,359 0 0 -3,985 0
Annual Cost Burden (Dollars) 36,088 32,334 0 0 3,754 0
No
No
$272,880
No
    Yes
    Yes
No
No
No
No
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.
03/01/2022