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) Modified 2425 412 821
EE -5B - Supplemental Employment Evidence - DOE Contractors Modified 6816 3408 2308
EE 5A - Supplemental Employment Evidence Modified 163 82 55
EEOICP Forms for Individuals or Households Modified 65362 18273 22136 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 Letter to Claimant
Form EE-9 Letter to Claimant
Form EE-10 Letter to Claimant
Form and Instruction EE-20 Letter to Claimant
Form EE-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-13 Letter to State Workers Compensation Authorities
Form and Instruction EE-17B Physician's Certification of Necessity Under the EEOICPA
Form and Instruction EE-4 English Employment History Affidavit for a Claim under the EEOICPA
Form and Instruction EE-4 Employment History Affidavit for a Claim under the EEOICPA
Form and Instruction 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
EEOICP Forms for Private Sector Modified 3500 1750 1185 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 14 17 Form EE-13 Letter to State Workers' Compensation
Total burden requested under this ICR: 78317 23939 26522  
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