EE-22 (General Medical Authorization Request)

Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms

Documents and Forms

Document Name Document Type
Form EE-22 EE-22 (General Medical Authorization Request) Form and Instruction
Form EE-22 EE-22 (General Medical Authorization Request) Form and Instruction
EE-22 General Medical Authorization Request EE-22 (General Medical Authorization Request) (11).docx owcpmed.dol.gov/ Form and Instruction
EE-22 General Medical Authorization Request EE-22 (General Medical Authorization Request) (11).docx owcpmed.dol.gov/ Form and Instruction

Information Collection (IC) Details

IC Title:	EE-22 (General Medical Authorization Request)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 30.400(a) 20 CFR 30.700

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EE-22	General Medical Authorization Request	EE-22 (General Medical Authorization Request) (11).docx	https://owcpmed.dol.gov/	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: DOL/OWCP-11	FR Citation: 81 FR 25765

Number of Respondents: 1,500	Number of Respondents for Small Entity: 393

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

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.