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:
202412-1240-003
Status:
Active
Previous ICR Reference No:
202109-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Energy Employees Occupational Illness Compensation Program Act Forms
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
05/09/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/01/2025
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2028
36 Months From Approved
05/31/2025
Responses
78,317
0
48,051
Time Burden (Hours)
23,939
0
16,374
Cost Burden (Dollars)
26,522
0
36,088
Abstract:
The information collected by these forms is used by claims examiners in OWCP to determine eligibility for compensation. The information, with the medical evidence and other supporting documentation, is used to determine whether the claimant is entitled to compensation under Part B or Part E of EEOICPA, and the amount of that compensation.
Authorizing Statute(s):
US Code:
42 USC 7384
Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
US Code:
42 USC 7385(s) through 11
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:
89 FR 90072
11/14/2024
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 14391
04/01/2025
Did the Agency receive public comments on this ICR?
No
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-13, EE-20 , EE-10, EE-17B, EE-3 English, EE-1 English, EE-2 English, EE-9 , Form EE-8 , EE-12 , EE-16 and EN-16, EE-17A, EE-4 English, EE-4, EE-4 Spanish
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
,
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
,
Letter to State Workers Compensation Authorities
,
Physician's Certification of Necessity Under the EEOICPA
,
Employment History Affidavit for a Claim under the EEOICPA
,
Employment History Affidavit for a Claim under the EEOICPA
,
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
EE-7, EE-17B
Medical requirements
,
Physician Certification of Medical Necessity under the EEOICPA
EEOICP Forms for State Governments
EE-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
78,317
48,051
0
30,266
0
0
Annual Time Burden (Hours)
23,939
16,374
0
7,565
0
0
Annual Cost Burden (Dollars)
26,522
36,088
0
-9,566
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
Burden hours increased from 16,374 to 23,939. There is an overall adjustment of +7,565 in burden hours due to an increase in the number of claims being adjudicated (+ 30,266 more responses). However, there has been a decrease in the operation and maintenance costs of -$9,566, due to the electronic submission of many responses. Responses increased from 48,051 to 78,317. However, there has been a decrease in the operation and maintenance costs from $36,088 to $26,523, due to the electronic submission of many responses.
Annual Cost to Federal Government:
$541,228
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:
Anjanette Suggs 202 354-9660 suggs.anjanette@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:
04/01/2025
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