OMB control number

Energy Employees Occupational Illness Compensation Program Act Forms

OMB 1240-0002 · DOL/OWCP.

OMB 1240-0002

The information collected by these forms is used by claims examiners in OWCP to determine eligibility for compensation. The information, with the medical evidence and other supporting documentation, is used to determine whether the claimant is entitled to compensation under Part B or Part E of EEOICPA, and the amount of that compensation.

The latest form for Energy Employees Occupational Illness Compensation Program Act Forms expires 2028-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)
EE -5B - Supplemental Employment Evidence - DOE Contractors
EE 5A - Supplemental Employment Evidence
EEOICP Forms for State Governments Form
EEOICP Forms for Private Sector Form
EEOICP Forms for Individuals or Households Form and Instruction

All Historical Document Collections

202603-1240-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2026-03-12
202412-1240-003	Revision of a currently approved collection	2025-04-01
202109-1240-002 Approved with change	Extension without change of a currently approved collection	2022-03-01
202008-1240-064 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-20
202004-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-04-12
202002-1240-019 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-02-25
201901-1240-001 Approved without change	Revision of a currently approved collection	2019-02-09
201610-1240-003 Approved without change	Revision of a currently approved collection	2016-12-30
201510-1240-002 Comment filed on proposed rule and continue	Revision of a currently approved collection	2015-11-18
201304-1240-001 Approved without change	Revision of a currently approved collection	2013-10-29
201004-1240-002 Approved without change	Revision of a currently approved collection	2010-08-09
201003-1240-002 Approved without change	Revision of a currently approved collection	2010-03-12

OMB Details

EEOICP Forms for Individuals or Households

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form EE-17B	Physician's Certification of Necessity Under the EEOICPA	eclaimant.dol.gov	Form and instruction
Form 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	eclaimant.dol.gov	Form and instruction
Form EE-4	Employment History Affidavit for a Claim under the EEOICPA	www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Form and instruction
Form EE-4 English	Employment History Affidavit for a Claim under the EEOICPA	www.dol.gov/ agencies/owcp/energy/regs/compliance/claim_forms	Form and instruction
Form EE-17A	CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT	Paper Only	Form and instruction
Form EE-16 and EN-16	Letter to Claimant	Paper Only	Form
Form EE-12	Letter to Claimant	Paper Only	Form
Form Form EE-8	Letter to Claimant	Paper Only	Form
Form EE-9	Letter to Claimant	Paper Only	Form
Form EE-2 English	Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Form and instruction
Form EE-1 English	Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Form and instruction
Form EE-3 English	Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act	www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms	Form and instruction
Form EE-10	Letter to Claimant	Paper Only	Form
Form EE-20	Letter to Claimant	Paper Only	Form and instruction
Form EE-13	Letter to State Workers Compensation Authorities	Paper Only	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.