Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
EEOICP Forms for Individuals or Households Modified 60751 21299 28427 Form and Instruction EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
Form and Instruction EE-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
Form and Instruction EE-3 English Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act
Form and Instruction EE-4 English Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
Form Form EE-8 and EN-8 Letter to Claimant EE-8 and EN-8
Form EE-9 and EN-9 Letter to Claimant EE-9 and EN-9
Form EE-10 and EN-10 Letter to Claimant EE-10 and EN-10
Form and Instruction EE-20 and EN-20 Letter to Claimant EE-20 and EN-20
Form and Instruction EE-1 Spanish Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia
Form and Instruction EE-2 Spanish Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia
Form and Instruction EE-3 Spanish Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia
Form and Instruction EE-4 Spanish 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
Form EE-11A and EN-11A Letter to Claimant EE-11A and EN-11A
Form EE-11B and EN-11B Letter to Claimant EE-11B and EN-11B
Form EE-12 and EN-12 Letter to Claimant EE-12 and EN-12
Form EE-16 and EN-16 Letter to Claimant EE-16 and EN-16
Form and Instruction EE-17B Physician's Certification of Medical Necessity Under the Energy Employees Occupational Illness Compensation Program Act
Form EE-17A Claim for Home Health Care, Nursing Home, or Assited Living Benefits Under the Energy Employees Occupational Programs Act
EEOICP Forms for Private Sector Modified 6523 1631 3052 Form and Instruction EE-7 English Medial Requirements under rhe Energy Employees Occupational Illness Compensation Program Act
Form and Instruction EE-7 Spanish Requisitos medicos segun la Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de la Energia
EEOICP Forms for State Governments Modified 51 816 24 Form EE-13 and EN-13 EEOICP forms for State Workers' Compensation Agency
Total burden requested under this ICR: 67325 23746 31503  
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