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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
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
Retrieve Notice of Action (NOA)
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
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.
Authorizing Statute(s):
US Code:
42 USC 7384
Name of Law: EEOICPA of 2000
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
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
Medical Requirements 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 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
,
Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
,
Claim for Survivor 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 Ilness Compensation Program Act
,
Medical Requirements under the Energy Employees Occupational Illness Compensation Program ACt
,
Letter to Claimant
,
Letter to Claimant
,
Letter to Claimant
,
Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act
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:
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
Agency Contact:
Sheldon Turley 202-693-5337 Turley.Sheldon@dol.gov
Common Form ICR:
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:
(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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