Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act

Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act

OMB: 1240-0063

IC ID: 267380

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act
 
No New
 
Required to Obtain or Retain Benefits
 
20 CFR 30.103 20 CFR 30.505 20 CFR 30.620 20 CFR 30.100

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction EE-1 Claim for Consequential Illness under the EEOICPA Claim for Consequential Illness under the EEOICPA (EE-1)_FINAL.docx https://www.dol.gov/agencies/owcp/energy/regs/compliance/claims_forms Yes Yes Fillable Fileable

Income Security General Retirement and Disability

DOL/OWCP-11  81 FR 84621

2,425 0
   
Individuals or Households
 
   70 %

  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 4,850 0 4,850 0 0 0
Annual IC Time Burden (Hours) 810 0 810 0 0 0
Annual IC Cost Burden (Dollars) 1,120 0 1,120 0 0 0

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