EEOICP Forms for Private Sector

Energy Employees Occupational Illness Compensation Program Act Forms

OMB: 1240-0002

IC ID: 178683

Information Collection (IC) Details

View Information Collection (IC)

EEOICP Forms for Private Sector
 
No Modified
 
Required to Obtain or Retain Benefits
 
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

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

Income Security General Retirement and Disability

DOL/OWCP-11  81 FR 25868

6,479 0
   
Private Sector Businesses or other for-profits
 
   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

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