CPWR-Employment Response Report

 

Section 1 – Employment to be Researched   (To be completed by DOL)  

 

     

    Employer (i.e. Contractor- Subcontractor)         

  Facility (i.e. Oak Ridge/Y-12)

  Position Title

 

Periods of Employment Requiring Verification

 

Period 1:                                                      c Contractual Relationship    c  Proof of Employment    c Employment on the Premises

 

Period 2:                                                  c Contractual Relationship    c  Proof of Employment    c Employment on the Premises

 

Period 3:                                                           c Contractual Relationship    c  Proof of Employment    c Employment on the Premises

 

Period 4:                                                           c Contractual Relationship    c  Proof of Employment    c Employment on the Premises

 

Section 2 – CPWR Research Results   (To be completed by CPWR)

 

Type of Record           Eligible Construction Worker  ¨Y ¨N

Located

Not Located

N/A

Result/Evidence

Positive

Negative

A. Union Dispatch/Log -

c

c

c

c

c

B. Pension Fund -

c

c

c

c

c

C. Health & Welfare -

c

c

c

c

c

D. Former Worker Program - Interview Date -

c

c

c

c

c

E. Facility/Site -

c

c

c

c

c

F. Other -

 

 

     c

c

c

c

c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Contacts Identified (If known):

 

Name

Address

Telephone

Comment

a

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

c

 

 

 

 

 

 

d

 

 

 

 

 

CPWR Contact Information (Completed by person doing CPWR records search)

 

NAME_____________________________________________________ DATE _______________________

 

SIGNATURE________________________________________________

 

TELEPHONE________________________________________________EMAIL______________________

 

 

    

Date

 

 

                             COVERED EMPLOYEE: 

                             CLAIMANT:

                             FILE NUMBER:

 

Dear:

 

This letter is in reference to the claim you submitted on (Filing Date) under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) for (Covered Diagnosis).  We are in the process of verifying {your or Mr./Ms/Mrs.}employment at the {facility/location/employer/dates}.  To date, we have been able to verify {summarize facts of verified employment}.

 

However, {The Department of Energy or Corporate Verifier} was unable to verify your employment at Facility/Location/employer/Dates.

 

Because you indicated on the Employment History for Claim under EEOICPA- Form EE-3, an occupation or employer which normally performed work related to a construction or a building trade, we are referring your case to The Center to Protect Workers’ Rights (CPWR).  The Department of Labor has contracted with CPWR to research and obtain employment records for those employees who may have worked or belonged to a union associated with the construction or building trades (i.e. laborer, teamster, plumbers).  CPWR performs research and training for the Building and Construction Trades Department under the American Federation of Labor-Congress of Industrial Organizations (AFL-CIO), and therefore has direct access to union records across the country.  

 

It is possible a representative from CPWR may contact you to clarify questions they may have regarding (your/Employee’s Name) employment history.  Please know they are not your assigned claims examiner and can not provide you with the status of your claim or collect any documentation related to your case.   If you have any questions related to your claim or CPWR’s involvement please contact the {District Office at XXX-XXX-XXXX}.

 

Sincerely,

 

 

Claims Examiner