Energy Employees Occupational Illness Compensation Program Act Forms (Various)

Forms and Documents

Document Name	Status
Form EE-20 Energy Employees Occupational Illness Compensation Program Act Forms (Various) Form and Instruction	Modified
1215-0197 Form EE-9 and EN-9 skin.expiration date 2007(2006 clearance).doc Supplementary Document	2006-10-05
1215-0197 Form EE-8 and EN-8 lung.expiration aug 2007(2006 clearance.doc Supplementary Document	2006-10-05
1215-0197 Form EE-10.expiration date aug 2007(2006 clearance).doc Supplementary Document	2006-10-05
83-C_1215-0197(07-11-06).pdf Justification for No Material/Nonsubstantive Change	2006-09-27

IC Document Collections

IC ID	Document Title	Status
13934	Energy Employees Occupational Illness Compensation Program Act Forms (Various) Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0197	ICR Reference No: 200609-1215-013
Status: Historical Active	Previous ICR Reference No: 200506-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Energy Employees Occupational Illness Compensation Program Act Forms (Various)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/03/2007
	Date Received in OIRA: 10/05/2006
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2007	08/31/2007	08/31/2007
Responses	92,763	0	92,763
Time Burden (Hours)	41,378	0	41,378
Cost Burden (Dollars)	22,000	0	22,000

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Abstract: Form 83-C was submitted to OMB on July 11, 2006 requesting approval for the Spanish-language versions of approved Forms EE-1, EE-2, EE-3, EE-4, and EE-7 for use in this information collection. The inclusion of these forms will not increase the previously approved burden hours. These forms are required to determine a claimant's eligibility for compensation under the EEOICPA, and are required to enable eligible claimants to receive benefits. The Spanish versions of the forms listed above will be available for electronic submission once approval for use is received from OMB.

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Authorizing Statute(s): US Code: 42 USC 7384 Name of Law: EEOICPA of 2000
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Energy Employees Occupational Illness Compensation Program Act Forms (Various)	EE-1 English, EE-2 English, EE-3 English, EE-4 English, EE-7 English, EE-8, EE-9, EE-10, EE-20, EE-2 Spanish, EE-1 Spanish, EE-7 Spanish, EE-3 Spanish, EE-4 Spanish	Letter to Claimant ,   Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Medical Requirements under the Energy Employees Occupational Illness Compensation Program ACt ,   Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act ,   Energy Employees Occupational Illness Compensation Program Act Forms. (Various) ,   Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Medical Requirements under the Energy Employees Occupational Illness Compensation Act ,   Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act ,   Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act ,   Letter to Claimant ,   Letter to Claimant ,   Employment History Affidavit for a Claim Under the Energy Employees Occupational Ilness Compensation Program Act

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ICR Summary of Burden

	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	92,763	92,763	0	0	0	0
Annual Time Burden (Hours)	41,378	41,378	0	0	0	0
Annual Cost Burden (Dollars)	22,000	22,000	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/05/2006

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