EEOICP Forms for Individuals or Households

Energy Employees Occupational Illness Compensation Program Act Forms

OMB: 1240-0002

IC ID: 13934

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Information Collection (IC) Details

View Information Collection (IC)

EEOICP Forms for Individuals or Households
 
No Modified
 
Required to Obtain or Retain Benefits
 
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

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 EE 1.pdf 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 EE 2.pdf 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 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 EE-4-Spa_ES.2024.pdf https://eclaimant.dol.gov Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

DOL/OWCP-11  81 FR 25868

65,362 0
   
Individuals or Households
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 65,362 0 27,339 0 0 38,023
Annual IC Time Burden (Hours) 18,273 0 6,647 0 0 11,626
Annual IC Cost Burden (Dollars) 22,136 0 -8,663 0 0 30,799

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