View Information Collection Request (ICR) Package
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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:
1240-0002
ICR Reference No:
202109-1240-002
Status:
Historical Active
Previous ICR Reference No:
202008-1240-064
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Energy Employees Occupational Illness Compensation Program Act Forms
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
05/04/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
03/01/2022
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2025
36 Months From Approved
05/31/2022
Responses
48,051
0
60,294
Time Burden (Hours)
16,374
0
20,359
Cost Burden (Dollars)
36,088
0
32,334
Abstract:
The Energy Employee forms are required to determine a claimant's eligibility for compensation under the Energy Employee Occupation Illness Compensation Program Act and are required to enable eligible claimants to receive benefits.
Authorizing Statute(s):
US Code:
42 USC 7385(s) through 11
Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
US Code:
42 USC 7384
Name of Law: Energy Employees Occupational Illness Compensation Program Act 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
60-day Notice:
Federal Register Citation:
Citation Date:
86 FR 56986
10/13/2021
30-day Notice:
Federal Register Citation:
Citation Date:
87 FR 11482
03/01/2022
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
6
IC Title
Form No.
Form Name
EE - 7A - Report of Occupational Illness (Part B)/Report of Covered Illness (Part E)
EE -5B - Supplemental Employment Evidence - DOE Contractors
EE 5A - Supplemental Employment Evidence
EEOICP Forms for Individuals or Households
EE-4-Spa, EE-4, EE-20 and EN-20, EE_10 and EN-10, EE-2 Spanish, EE-1 English, EE-1 Spanish, EE-3 English, EE-3 Spanish, EE-2 English, EE-9 and EN-9, Form EE-8 and EN-8, EE-11A and EN-11A, EE-11B and EN-11B, EE-12 and EN-12, EE-16 and EN-16, EE-17A
Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
,
Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act
,
Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act
,
Letter to Claimant
,
Letter to Claimant
,
Letter to Claimant
,
Letter to Claimant
,
Reclamacion de beneficios segun la Ley del Programa de Indemnizaciom por Enfermedades Ocupacionales para Empleados del Sector de la Energia
,
Reclaamacion de beneficios de sobreviviente segun las Ley del Programa de Indemnizacion por Enfermedades Ocupacionales para Empleados del Sector de las Energia
,
Historial de empleo para reclamacion segun la Ley del Programa de Indemnizacion por Enfermedades Ocupscionales para Empleados del Sector de la Energia
,
Letter to Claimant
,
Letter to Claimant
,
Letter to Claimant
,
Letter to Claimant
,
CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT
,
Affidavit in support of work history - Spanish
,
Affidavit in support of work history
EEOICP Forms for Private Sector
EE-7-Spa, EE-7, EE-17B
Medical requirements - Spanish
,
Medical requirements
,
Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments
EE-13 with EN-13
Letter to State Workers' Compensation
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
48,051
60,294
0
0
-12,243
0
Annual Time Burden (Hours)
16,374
20,359
0
0
-3,985
0
Annual Cost Burden (Dollars)
36,088
32,334
0
0
3,754
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:
$272,880
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
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:
03/01/2022
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