EE-11A/EN-11A: Response Requested-Impairment Benefits Response Form

Date:

Case ID Number:
Response requested

NAME
STREET ADDRESS
CITY, STATE ZIP

First Request
Second Request
Final Request

Dear :
This letter is in regard to your claim under Part E of the Energy Employees Occupational
Illness Compensation Program Act (EEOICPA). Your claim has been accepted for the
As such, you may be eligible for a monetary award for
following illness(es):
permanent impairment caused by the accepted illness(es).
“Whole body impairment” (or “impairment”) is a percentage rating that represents
the extent of impairment of a person based on the organ(s) and or system(s) affected by
the accepted illness(es). The percentage of impairment reflects how severely your
accepted illness(es) affect your body as a whole. The available monetary benefit is
$2,500 for every percentage point, up to a maximum monetary award of $250,000 under
Part E.
An impairment rating must be performed by an appropriate physician once your accepted
illness has reached maximum medical improvement, meaning that it is unlikely to
improve with additional treatment. In order for a physician to be considered able to
perform impairment evaluations under EEOICPA, the physician must hold a valid
medical license and Board certification (or eligibility) in an appropriate field of expertise.
The physician must also be certified by the American Board of Independent Medical
Examiners or the American Academy of Disability Evaluating Physicians, or possess the
requisite professional experience and medical work background in interpreting the
American Medical Association’s Guides to the Evaluation of Permanent Impairment
(AMA’s Guides) to provide such ratings.
The impairment evaluation must be well-reasoned and performed in accordance with the
Fifth edition of the AMA’s Guides, and include references to the pages and tables used in
arriving at the impairment rating.
If you believe you may qualify and wish to claim impairment benefits, please complete
If you have a disability (a substantially limiting physical or mental impairment), please contact our office
for information about the kinds of help available, such as communication assistance (alternate formats
or sign language interpretation), accommodations and modification.

OMB Control No:
Expiration Date:

1240-0002
03/31/2022

EE-11A
November 2016
Page 1

the enclosed Form EN-11A and be sure to provide the following information:



Check “YES” to indicate that you are seeking impairment benefits.
Check one of the two options to indicate who you would like to perform your
impairment evaluation. If you decide to select your own physician to perform the
impairment evaluation, the physician must demonstrate that he or she is qualified
as noted above. For example, the physician may submit a statement identifying
his/her specific expertise and knowledge of the AMA’s Guides (i.e., years
performing ratings, experience in rating the given condition/body part).

If you elect not to pursue an impairment claim at this time, please check “NO” on Form
EN-11A and we will not further develop the issue. Also, if this letter is marked above as
a “Final Request” and we do not hear from you, we will also not develop this issue
further. However, you retain the right to pursue an impairment claim in the future simply
by notifying us in writing and sending it to the address at the bottom of the enclosed
Form EN-11A.
We would appreciate receiving your written response within 30 days. If you have any
questions regarding this letter or impairment benefits in general, please do not hesitate to
contact me. You may call me at .

Sincerely,
Name
Title
City District Office
Enc:

Pamphlet, “How Do I qualify for an Impairment Award”
EN-11A

OMB Control No:
Expiration Date:

1240-0002
03/31/2022

EE-11A
November 2016
Page 2

PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby
notified that: (1) The Energy Employees Occupational Illness Compensation Program
Act (42 USC 7384 et seq.) (EEOICPA) is administered by the Office of Workers’
Compensation Programs of the U.S. Department of Labor, which receives and maintains
personal information on claimants and their immediate families. (2) Information
received will be used to determine eligibility for, and the amount of, benefits payable
under EEOICPA, and may be verified through computer matches or other appropriate
means. (3) Information may be disclosed to physicians and other health care providers
for use in providing treatment, performing evaluations for the Office of Workers’
Compensation Programs, and for other purposes related to the medical management of
the claim. (4) Failure to disclose all requested information may delay the processing of
the claim or the payment of benefits, or may result in an unfavorable decision.
PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to the information collections on this form unless it displays a valid OMB control
number. Public reporting burden for this collection of information is estimated to
average 15 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering the data needed, and completing and reviewing the
collection of information. The obligation to respond to this collection is required to
obtain EEOICPA benefits (20 CFR 30.505). Send comments regarding the burden
estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, send them to the U.S. Department of Labor, Office of Workers’
Compensation Programs, Room S3524, 200 Constitution Avenue N.W., Washington,
D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE/EN-11A. Do not
submit the completed form to this address.

OMB Control No:
Expiration Date:

1240-0002
03/31/2022

EE-11A
November 2016
Page 3

Case ID Number:
Employee Name:
Impairment Benefits Response Form
YES, I wish to pursue a claim for impairment benefits for my accepted illness(es).
If you checked YES above, you must check one of the two options below and provide the
necessary information:
I want to have DEEOIC arrange for a qualified physician, known as a Contract
Medical Consultant (CMC), to perform my impairment evaluation.
I want to select my own qualified physician to perform my impairment
evaluation. The physician’s name, address and phone number is:
Physician Name:____________________________________
Address: __________________________________________
___________________________________________________
Phone No:(
)____ ___________ ______________
NO, I am not pursuing impairment benefits at this time. I understand that I can file
for impairment benefits in the future by submitting a signed statement to that effect to the
district office.
Signature (Required)

Signature

Date

Mail EN-11A to: U.S. Department of Labor, OWCP/DEEOIC
P.O. Box 34930
San Antonio, TX 78265
Or you may fax it to:

OMB Control No:
Expiration Date:

1240-0002
03/31/2022

EN-11A
November 2016