Forms

 

Below are listed the various forms used within the DEEOIC.

 

Form EE-1

Claim for Benefits under EEOICPA

Form EE-2

Claim for Survivor Benefits under EEOICPA

Form EE-3

Employment History for Claim under EEOICPA

Form EE-4

Employment History Affidavit for Claim under the EEOICPA

Form EE-5

Department of Energy's Response to Employment History for Claim under the EEOICPA

Form EE-7

Medical Requirements under the EEOICPA

Form EE/EN-8

Racial/Ethnic Identification under EEOICPA

Form EE/EN-9

Smoking History Identification under EEOICPA

Form EE-10

Claim for Additional Wage-Loss and/or Impairment under the EEOICPA

Form EE-12

Dose Reconstruction Consent Form

Form EE-13/EN-13

Request for Information with Respect to State Worker’s Compensation Claims

Form EE/EN-20

Acceptance of Payment under the EEOICPA

Form DL 1-520

Request under the Freedom of Information Act

Form ESA-67a

Privacy Act Record System Log of Disclosures

Form OWCP-04

Uniform Bill for Medical Expenses

Form OWCP-915

Claim for Medical Reimbursement

Form OWCP-957

Medical Travel Refund Request

Form OWCP-1500

Health Insurance Claim

Form SSA-581

Authorization to Obtain Earnings Data from the SSA