OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Energy Employees Occupational Illness Compensation Program Act Forms

ICR 202002-1240-019 · OMB 1240-0002 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Unchanged
Form and Instruction
 Unchanged
Form and Instruction
 Unchanged
Justification for No Material/Nonsubstantive Change
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2020-02-24
Supplementary Document
2013-06-11
Supporting Statement A
2019-02-01
IC Document Collections
IC ID
Document
Title
Status
178684 Unchanged
178683 Unchanged
13934 Unchanged
ICR Details
1240-0002 202002-1240-019
Historical Active 201901-1240-001
DOL/OWCP
Energy Employees Occupational Illness Compensation Program Act Forms
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 02/27/2020
Retrieve Notice of Action (NOA) 02/25/2020
  Inventory as of this Action Requested Previously Approved
03/31/2022 03/31/2022 03/31/2022
60,294 0 60,294
20,359 0 20,359
32,334 0 32,334
PO Box Address change for the EE-8/EN-8, EE-9/EN-9, EE-10/EN-10, EE-11A/EN-11A, EE-11B/EN-11B, EE-12/EN-12 and EE-16/EN-16 only. The Energy Employee forms are required to determine a claimant's eligibility for compensation under the Energy Employee Occupation Illness Compensation Program Act and are required to enable eligible claimants to receive benefits.
US Code: 42 USC 7385(s) through 11 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
  
None
1240-AA08 Final or interim final rulemaking 84 FR 3026 02/08/2019
  80 FR 72296 11/18/2015
80 FR 72296 11/18/2015
Yes
3
IC Title Form No. Form Name
EEOICP Forms for State Governments EE-13 with EN-13 Letter to State Workers' Compensation
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 Individuals or Households EE-20 and EN-20, EE-4 Spanish, EE_10 and EN-10, 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, EE-17B, EE-17A 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 ,   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 ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   Letter to Claimant ,   CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT ,   PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION
  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 60,294 60,294 0 0 0 0
Annual Time Burden (Hours) 20,359 20,359 0 0 0 0
Annual Cost Burden (Dollars) 32,334 32,334 0 0 0 0
No
No
There is an overall adjustment of -180 in burden hours due to a decrease in the number of claims being adjudicated, balanced against an increase in the amount of information required by some of those claims, and the new EE-17A and EE-17B. There has also been a slight increase in the operation and maintenance costs of +$4,534, due to an increase in the number of mailed responses, from $27,800 to $32,334.
$318,499
No
    Yes
    Yes
No
No
No
Uncollected
Sheldon Turley 202-693-5337 Turley.Sheldon@dol.gov
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/25/2020