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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
EEOICP Forms for Individuals or Households
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 30.101
20 CFR 30.103
20 CFR 30.102
20 CFR 30.111
20 CFR 30.221
20 CFR 30.114
20 CFR 30.206
20 CFR 30.207
20 CFR 30.212
20 CFR 30.113
20 CFR 30.100
20 CFR 30.213
20 CFR 30.214
20 CFR 30.222
20 CFR 30.417
20 CFR 30.231
20 CFR 30.415
20 CFR 30.416
20 CFR 30.620
20 CFR 30.505
20 CFR 30.806
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
EE-8
Letter to Claimant
Form EE-8 and EN-8 lung.EXP 8-31-07.doc
No
Paper Only
Form
EE-9
Letter to Claimant
Form EE-9 and EN-9 8-31-07.doc
No
Paper Only
Form and Instruction
EE-4 English
Employment History Affidavit for a Claim Under the Energy Employees Occupational Ilness Compensation Program Act
EE-4 (8-31-07).pdf
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-1 Spanish
Energy Employees Occupational Illness Compensation Program Act Forms. (Various)
EE1-Spa (June 11, 2006).doc
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-3 Spanish
Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
EE3-Spa (July 11, 2006).doc
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-3 English
Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
EE-3 (8-31-07).pdf
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-2 Spanish
Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act
EE2-Spa (July 11, 2006).doc
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-4 Spanish
Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act
EE4-Spa.doc
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-2 English
Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Program Act
EE-2 (8-31-07).pdf
http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-20
Letter to Claimant
EN-20 (8-31-07).pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-1 English
Claims for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
EE-1 (8-31-07).pdf
http://www.dol.gov./esa/regs/compliance/owcp/eeoicp/clainsforms.htm
Yes
Yes
Fillable Fileable Signable
Form and Instruction
EE-10
Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Act
EE-10 8-31-07.pdf
No
Paper Only
Other-Letter
EE-12 and EN-12 (draft) (2007 clearance).doc
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
DOL/ESA 49
FR Citation:
67 FR 16891
Number of Respondents:
58,349
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
58,349
0
4,000
-38,414
0
92,763
Annual IC Time Burden (Hours)
29,340
0
1,333
-13,371
0
41,378
Annual IC Cost Burden (Dollars)
4,629
0
0
-17,371
0
22,000
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.