Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E) New 277 69 0
EE -5B - Supplemental Employment Evidence - DOE Contractors New 2448 1224 0
EE 5A - Supplemental Employment Evidence New 773 387 0
EEOICP Forms for Individuals or Households Modified 38023 11626 30799 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 Form EE-8 and EN-8 Letter to Claimant
Form EE-9 and EN-9 Letter to Claimant
Form EE_10 and EN-10 Letter to Claimant
Form and Instruction EE-20 and EN-20 Letter to Claimant
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 EE-11A and EN-11A Letter to Claimant
Form EE-11B and EN-11B Letter to Claimant
Form EE-12 and EN-12 Letter to Claimant
Form EE-16 and EN-16 Letter to Claimant
Form and Instruction EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT
Form and Instruction EE-4-Spa Affidavit in support of work history - Spanish
Form and Instruction EE-4 Affidavit in support of work history
EEOICP Forms for Private Sector Modified 6479 2252 5248 Form EE-7-Spa Medical requirements - Spanish
Form EE-7 Medical requirements
Form and Instruction EE-17B Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments Modified 51 816 41 Form EE-13 with EN-13 Letter to State Workers' Compensation
Total burden requested under this ICR: 48051 16374 36088  
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