Employment Verification Sheet (EE-5)

EMPLOYMENT VERIFICATION SHEET
This form is used to verify the employment history of an employee named in a claim for compensation under the Energy Employees Occupational
Illness Compensation Program Act of 2000 (EEOICPA). The employment verification and certification must be completed by an official of the
Department of Energy. All attached documentation (EE-1 or EE-2 Claim for Benefits and EE-3 Employment History) should be reviewed prior
to completion.

EMPLOYEE INFORMATION (completed by DOE or DOL )

Employee Last Name

First Name

Employer Name

MI

Social Security Number

Department of Energy Facility

EMPLOYMENT VERIFICATION (completed by DOE)
You must select ONE of the following three options and provide the appropriate response. If the employee worked for multiple employers at the facility,
you may request additional Employment Verification Sheets from the district office handling the claim or make a copy of a blank sheet.

OPTION 1—

VERIFIED EMPLOYMENT

Verified Period 1 From
DOE employee

Contractor

Verified Period 2 From
DOE employee

Subcontractor

to
Contractor

Verified Period 4 From

OPTION 2—

Location of Employment Activities, if known (Building, Laboratory, Site, Mine, etc.)

to

Verified Period 3 From

DOE employee

Subcontractor

Contractor

DOE employee

Location of Employment Activities, if known (Building, Laboratory, Site, Mine, etc.)

to

Location of Employment Activities, if known (Building, Laboratory, Site, Mine, etc.)
Subcontractor
Location of Employment Activities, if known (Building, Laboratory, Site, Mine, etc.)

to
Contractor

Subcontractor

NO VERIFICATION IS POSSIBLE, BUT OTHER PERTINENT EVIDENCE EXISTS

The Department of Energy has conducted a reasonable search of available records and is unable to verify the accuracy of the claimed period of
employment. However, evidence has been identified that may assist the DOL claims examiner reach a determination of covered employment. Check
all that apply and attach pertinent documentation to this form. If needed, a narrative statement can be prepared to summarize findings or
provide clarification.

Security Clearance

Medical Health Records

Proof of Contractual or Subcontractual Relationship

Employee ID Badge

Dosimeter Badge Number

Other

OPTION 3—NO EVIDENCE EXISTS IN REGARD TO THE CLAIMED EMPLOYMENT
The Department of Energy has conducted a reasonable search of available records and is unable to identify any evidence that can be used to either
concur or disagree with the accuracy of claimed employment. Furthermore, no documentation or other evidence has been identified that could assist
the Department of Labor in making a determination of covered employment.

CERTIFICATION (completed by DOE)
By signing this employment sheet, the Department of Energy is acknowledging that it has conducted a reasonable search of available records and that
the information provided on this sheet accurately reflects the results of that search. For any period of claimed employment that is not verified by this
form, the Department of Energy acknowledges that it can neither concur nor disagree with the accuracy of claimed employment.

Telephone No: (

Print Name

)

Address

Date:

Signature

Reset

Print

EE-5 Employment Verification

INSTRUCTIONS FOR COMPLETING EE-5
DOE is to conduct a reasonable search of existing records in its possession or in the possession of certain of its contractors or other
vendors. The purpose of this record search is to determine if any documentation exists that can be used to verify the accuracy of
claimed employment for an employee of the DOE or certain DOE contractors or subcontractors. The EE-5 is intended to serve as the
official response to the accuracy of claimed employment.
The EE-5 is routed to the appropriate action site based on referral guidance provided by the DOE. The facility where employment is
claimed determines the DOE site handling the request. If you have received this form in error, please contact the referring district
office. The EE-5 Employment Verification Sheet is to be completed by an individual authorized to respond on behalf of the DOE.
EMPLOYEE INFORMATION
The DOL claims examiner will generally be responsible for listing employee name, SSN, claimed employer or DOL facility where
employment is alleged to have occurred. This information will be derived from the EE-1 or EE-2 claim form and the EE-3 work history.
A DOE representative may also complete this section in situations where employee information is available that was not listed by the
claimant or identified by the claims examiner.
EMPLOYMENT VERIFICATION
Select ONE of the three options and provide the appropriate response:
Option 1 - Verified Employment
If sufficient evidence exists that would allow the DOE to conclude that any period of claimed employment is verifiable, Option 1
should be marked. By verifying employment, the DOE representative is certifying that documentation or other data exists that
substantiates the following:
1. The employee worked for the claimed employer;
2. The claimed employer is/was either the DOE or a DOE contractor/subcontractor; and
3. The employee was engaged in employment activities on the premise of the covered facility.
For each period of verifiable employment, list the start and end date. Identify each separate period of continuous employment.
For certain contractors or subcontractors, it may be necessary to list multiple periods of continuous employment. If more space
is needed, complete a new Employment Verification Sheet and attach all the sheets for same employer together. Specify the
location within the premise of the covered facility where employment activities occurred. Be as specific as possible. Mark
whether the employee worked directly for the facility as a Department of Energy employee or a contractor or subcontractor at
the covered site.
Option 2 - No Verification is Possible, but Other Pertinent Evidence Exists
In certain situations, it may be that the DOE does not have sufficient evidence to verify the accuracy of the claimed period of
employment (The three criteria listed above), but other evidence exists that may be helpful in making a determination of covered employment. If this is the case, Option 2 should be marked and the type of evidence that exists is to be identified.
For example, an individual claims his father worked as a contractor at a covered DOE facility. Research conducted by the
DOE representative is unable to identify any personal information to verify employment. However, records are found that
establish the facility did have a contract with the employee’s company. In this situation, the DOE representative will mark that
verification is not possible, but other information is available. Check the entry next to “Proof of Contractual or Subcontractual
relationship” and attach a copy of the pertinent evidence to the form or provide a signed statement summarizing the findings.
Option 3 - No Evidence Exists in Regard to the Claimed Employment
If a reasonable search of records has failed to produce any documentation or other information that can be used to verify the
accuracy of the claimed period of employment, Option 3 should be selected. This is only to be marked if the DOE is reasonably certain that no documentation exists pertaining to the employee or his or her employer. Selecting Option 3 indicates that
DOE can neither concur nor disagree with the accuracy of alleged employment.
CERTIFICATION
Each separate employer sheet is to be signed by an official of the DOE responsible for the accuracy of any employment verification
data provided. If the same individual is certifying multiple employer sheets, it is only necessary to provide contact information on the
first sheet. All employer sheets must be signed by a representative of the DOE to be considered complete. The completed sheet is to
be returned to the referring Department of Labor district office.