Information Collection

EEOICP Forms for Individuals or Households

IC 13934 under ICR 202603-1240-001 · OMB 1240-0002.

⚠️ Notice: This information collection may be referencing outdated material.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

2026-05-28 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
Form EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act EEOICP Forms for Individuals or Households Form and Instruction
Form EE-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act EEOICP Forms for Individuals or Households Form and Instruction
Form EE-3 English Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act EEOICP Forms for Individuals or Households Form and Instruction
Form Form EE-8 Letter to Claimant EEOICP Forms for Individuals or Households Form
Form EE-9 Letter to Claimant EEOICP Forms for Individuals or Households Form
Form EE-10 Letter to Claimant EEOICP Forms for Individuals or Households Form
Form EE-20 Letter to Claimant EEOICP Forms for Individuals or Households Form and Instruction
Form EE-12 Letter to Claimant EEOICP Forms for Individuals or Households Form
Form EE-16 and EN-16 Letter to Claimant EEOICP Forms for Individuals or Households Form
Form EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT EEOICP Forms for Individuals or Households Form and Instruction
Form EE-13 Letter to State Workers Compensation Authorities EEOICP Forms for Individuals or Households Form and Instruction
Form EE-17B Physician's Certification of Necessity Under the EEOICPA EEOICP Forms for Individuals or Households Form and Instruction
Form EE-4 English Employment History Affidavit for a Claim under the EEOICPA EEOICP Forms for Individuals or Households Form and Instruction
Form EE-4 Employment History Affidavit for a Claim under the EEOICPA EEOICP Forms for Individuals or Households Form and Instruction
Form EE-4 Spanish 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 Individuals or Households Form and Instruction
EE-1 English Worker's Claim for Benefits Under the Energy Employees O Form EE-1-RECA Question Change 3.4.26.docx www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-2 English Survivor's Claim for Benefits Under the Energy Employees Form EE-2 RECA Question Change 3.4.26.docx www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-3 English Employment History for a Claim Under The Energy Employee EE 3.pdf www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
Form EE-8 Letter to Claimant EE-8 .2024.pdf Form
EE-9 Letter to Claimant EE-9 .2024.pdf Form
EE-10 Letter to Claimant EE-10-2024.pdf Form
EE-20 Letter to Claimant EE-20.2024.pdf Form and Instruction
EE-12 Letter to Claimant EE-12.2024.pdf Form
EE-16 and EN-16 Letter to Claimant EN-16.2024.pdf Form
EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LI EE-17A.6.24.2024.pdf Form and Instruction
EE-13 Letter to State Workers Compensation Authorities EE EN 13.pdf Form and Instruction
EE-17B Physician's Certification of Necessity Under the EEOICPA EE-17B.pdf eclaimant.dol.gov Form and Instruction
EE-4 English Employment History Affidavit for a Claim under the EEOIC EE 4.pdf www.dol.gov/ agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-4 Employment History Affidavit for a Claim under the EEOIC EE-4.2024.pdf www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-4 Spanish Declaración jurada sobre historial de empleo para reclam EE-4-Spa_ES.2024.pdf eclaimant.dol.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EEOICP Forms for Individuals or Households	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.620 20 CFR 30.207 20 CFR 30.103 20 CFR 30.102 20 CFR 30.231 20 CFR 30.415 20 CFR 30.416 20 CFR 30.222 20 CFR 30.214 20 CFR 30.806 20 CFR 30.221 20 CFR 30.113 20 CFR 30.101 20 CFR 30.213 20 CFR 30.111 20 CFR 30.417 20 CFR 30.505 20 CFR 30.100 20 CFR 30.114 20 CFR 30.206 20 CFR 30.212

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EE-1 English	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form EE-1-RECA Question Change 3.4.26.docx	https://www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-2 English	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	Form EE-2 RECA Question Change 3.4.26.docx	https://www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-3 English	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	EE 3.pdf	https://www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Yes	Yes	Fillable Fileable Signable
Form	Form EE-8	Letter to Claimant	EE-8 .2024.pdf		No		Paper Only
Form	EE-9	Letter to Claimant	EE-9 .2024.pdf		No		Paper Only
Form	EE-10	Letter to Claimant	EE-10-2024.pdf		No		Paper Only
Form and Instruction	EE-20	Letter to Claimant	EE-20.2024.pdf		No		Paper Only
Form	EE-12	Letter to Claimant	EE-12.2024.pdf		No		Paper Only
Form	EE-16 and EN-16	Letter to Claimant	EN-16.2024.pdf		No		Paper Only
Form and Instruction	EE-17A	CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT	EE-17A.6.24.2024.pdf		Yes	No	Paper Only
Form and Instruction	EE-13	Letter to State Workers Compensation Authorities	EE EN 13.pdf		No		Paper Only
Form and Instruction	EE-17B	Physician's Certification of Necessity Under the EEOICPA	EE-17B.pdf	https://eclaimant.dol.gov	Yes	No	Fillable Fileable
Form and Instruction	EE-4 English	Employment History Affidavit for a Claim under the EEOICPA	EE 4.pdf	https://www.dol.gov/ agencies/owcp/energy/regs/compliance/claim_forms	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-4	Employment History Affidavit for a Claim under the EEOICPA	EE-4.2024.pdf	https://www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Yes	Yes	Fillable Fileable Signable
Form and Instruction	EE-4 Spanish	DeclaraciÃ³n jurada sobre historial de empleo para reclamaciÃ³n segÃºn la Ley del Programa de IndemnizaciÃ³n por Enfermedades Ocupacionales para Empleados del Sector de la EnergÃa	EE-4-Spa_ES.2024.pdf	https://eclaimant.dol.gov	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

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: 65,362	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Previously Approved
Annual Number of Responses for this IC	65,362	65,362
Annual IC Time Burden (Hours)	18,273	18,273
Annual IC Cost Burden (Dollars)	22,136	22,136

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.

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