Energy Employees Occupational Illness Compensation Program Act Forms

Forms and Documents

Document Name	Status
Form EE-7 English EEOICP Forms for Private Sector Form and Instruction	Modified
Form EE-16 and EN-16 EEOICP Forms for Individuals or Households Form	Modified
Supporting Regulations.pdf Supplementary Document	2013-06-11
SS for renewal of 1240-0002.docx Supporting Statement A	2013-10-21

IC Document Collections

IC ID	Document Title	Status
178684	EEOICP Forms for State Governments Other-EEOICP forms for State Government	Modified
178683	EEOICP Forms for Private Sector Form and Instruction	Modified
13934	EEOICP Forms for Individuals or Households Form	Modified

ICR Details

OMB Control No: 1240-0002	ICR Reference No: 201304-1240-001
Status: Historical Active	Previous ICR Reference No: 201004-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Energy Employees Occupational Illness Compensation Program Act Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/27/2013
	Date Received in OIRA: 10/29/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved	12/31/2013
Responses	66,020	0	36,966
Time Burden (Hours)	23,190	0	17,477
Cost Burden (Dollars)	28,089	0	2,317

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Abstract: The EE forms are required to determine a claimant's eligibility for compensation under the EEOICPA and are required to enable eligible claimants to receive benefits.

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Authorizing Statute(s): 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
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 40513	07/05/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 64539	10/29/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
EEOICP Forms for Private Sector	EE-7 English, EE-7 Spanish	Medial Requirements under rhe Energy Employees Occupational Illness Compensation Program Act ,   Requisitos medicos segun la Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de la Energia
EEOICP Forms for State Governments
EEOICP Forms for Individuals or Households	EE_10 and EN-10, EE-20 and EN-20, EE-4 Spanish, EE-2 Spanish, EE-1 Spanish, EE-3 English, EE-3 Spanish, EE-1 English, EE-2 English, EE-4 English, EE-9 and EN-9, Form EE-8 and EN-8, EE-11A and EN-11A, EE-11B and EN-11B, EE-12 and EN-12, EE-16 and EN-16	Letter to Claimant ,   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 ,   Employment History Affidavit 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 ,   Letter to Claimant ,   Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia ,   Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia ,   Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia ,   Declaracion jurada sobre historial de empleo para reclamacion sequin la Ley del Programa de Indemnizacioon por Enfermedades Ocupacionales para Empleados del Sector de la Energia

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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	66,020	36,966	0	0	29,054	0
Annual Time Burden (Hours)	23,190	17,477	0	0	5,713	0
Annual Cost Burden (Dollars)	28,089	2,317	0	0	25,772	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: The 2010 numbers entered into ROCIS were incorrect; therefore the "Change Due to Adjustment in Agency Estimate" numbers include the corrections. There is an overall adjustment of +5,713 in burden hours. This is partially due to a shift in the type of claims being adjudicated to those that require the submission of more information. There has also been an increase in the operation and maintenance cost of +$25,772. This is partially due to mailing costs increasing. The only change to any of the forms in this renewal was to the form EE/EN-20. The only changes were the deletion of the option to request payment by paper check, per Treasury's instructions.

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Annual Cost to Federal Government: $395,847

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 10/29/2013

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