OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Energy Employees Occupational Illness Compensation Program Act Forms

ICR 202412-1240-003 · OMB 1240-0002 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form EE-13 EEOICP Forms for State Governments Form Modified Repair queued
Form EE-7 EEOICP Forms for Private Sector Form Modified Repair queued
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction Modified Missing upstream
Supporting Statement for 1240-0002 4 1 25.docx Supporting Statement A Uploaded 2025-04-01 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) Modified
251536 EE -5B - Supplemental Employment Evidence - DOE Contractors Modified
251535 EE 5A - Supplemental Employment Evidence Modified
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 202412-1240-003
Historical Active 202109-1240-002
DOL/OWCP
Energy Employees Occupational Illness Compensation Program Act Forms
Revision of a currently approved collection   No
Regular
Approved with change 05/09/2025
Retrieve Notice of Action (NOA) 04/01/2025
  Inventory as of this Action Requested Previously Approved
05/31/2028 36 Months From Approved 05/31/2025
78,317 0 48,051
23,939 0 16,374
26,522 0 36,088
The information collected by these forms is used by claims examiners in OWCP to determine eligibility for compensation. The information, with the medical evidence and other supporting documentation, is used to determine whether the claimant is entitled to compensation under Part B or Part E of EEOICPA, and the amount of that compensation.
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
Not associated with rulemaking
  89 FR 90072 11/14/2024
90 FR 14391 04/01/2025
No
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-13, EE-20 , EE-10, EE-17B, EE-3 English, EE-1 English, EE-2 English, EE-9 , Form EE-8 , EE-12 , EE-16 and EN-16, EE-17A, EE-4 English, EE-4, EE-4 Spanish 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 ,   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 ,   Letter to State Workers Compensation Authorities ,   Physician's Certification of Necessity Under the EEOICPA ,   Employment History Affidavit for a Claim under the EEOICPA ,   Employment History Affidavit for a Claim under the EEOICPA ,   Declaración jurada sobre historial de empleo para reclamación según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía
EEOICP Forms for Private Sector EE-7, EE-17B Medical requirements ,   Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments EE-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 78,317 48,051 0 30,266 0 0
Annual Time Burden (Hours) 23,939 16,374 0 7,565 0 0
Annual Cost Burden (Dollars) 26,522 36,088 0 -9,566 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Burden hours increased from 16,374 to 23,939. There is an overall adjustment of +7,565 in burden hours due to an increase in the number of claims being adjudicated (+ 30,266 more responses). However, there has been a decrease in the operation and maintenance costs of -$9,566, due to the electronic submission of many responses. Responses increased from 48,051 to 78,317. However, there has been a decrease in the operation and maintenance costs from $36,088 to $26,523, due to the electronic submission of many responses.
$541,228
No
    Yes
    Yes
No
No
No
No
Anjanette Suggs 202 354-9660 [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.
04/01/2025