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