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EEOICP Forms for Private Sector
Energy Employees Occupational Illness Compensation Program Act Forms
OMB: 1240-0002
IC ID: 178683
OMB.report
DOL/OWCP
OMB 1240-0002
ICR 202109-1240-002
IC 178683
( )
Documents and Forms
Document Name
Document Type
Form EE-7-Spa
EEOICP Forms for Private Sector
Form
EE-7-Spa Medical requirements - Spanish
Draft EE-7-Spa.docx
Form
EE-7-Spa Medical requirements - Spanish
Draft EE-7-Spa.docx
Form
EE-7 Medical requirements
Draft EE-7.docx
Form
EE-7 Medical requirements
Draft EE-7.docx
Form
EE-17B Physician Certification of Medical Necessity under the E
EE-17B.docx
Form and Instruction
EE-17B Physician Certification of Medical Necessity under the E
EE-17B.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
EEOICP Forms for Private Sector
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 30.222
20 CFR 30.106
20 CFR 30.215
20 CFR 30.103
20 CFR 30.415 through 30.417
20 CFR 30.207
20 CFR 30.905
20 CFR 30.232 (a) and (b)
20 CFR 30.907
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
EE-7-Spa
Medical requirements - Spanish
Draft EE-7-Spa.docx
Yes
No
Printable Only
Form
EE-7
Medical requirements
Draft EE-7.docx
Yes
No
Printable Only
Form and Instruction
EE-17B
Physician Certification of Medical Necessity under the EEOICPA
EE-17B.docx
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
DOL/OWCP-11
FR Citation:
81 FR 25868
Number of Respondents:
6,479
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
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
6,479
0
0
990
0
5,489
Annual IC Time Burden (Hours)
2,252
0
0
880
0
1,372
Annual IC Cost Burden (Dollars)
5,248
0
0
2,229
0
3,019
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.