Issue Date:  February 10, 2014



Effective Date:  February 10, 2014



Expiration Date:  February 10, 2015



Subject:  Renewed EEOICPA forms.


Background:  Every three years, the Division of Energy Employees Occupational Illness Compensation (DEEOIC) submits a package to the Office of Management and Budget (OMB) that requests renewal of DEEOIC’s authority to use 19 forms that collect information necessary for the adjudication of claims under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).  On December 31, 2013, OMB granted DEEOIC’s request and renewed the EEOICPA forms for another three years of use through December 31, 2016.


References:  Federal (EEOICPA) Procedure Manual, Chapters 2-900, 2-1300 and 3-700.


Purpose:  To provide guidance following OMB’s renewal of 19 EEOICPA forms.


Applicability:  All DEEOIC staff.




1.  As noted above, the 19 EEOICPA forms in OMB Control No. 1240-0002 have been renewed for use through December 31, 2016.  The 19 forms are listed below:


EE-1                         EE/EN-8

EE-1 (Spanish version)       EE/EN-9

EE-2                         EE/EN-10

EE-2 (Spanish version)       EE/EN-11A

EE-3                         EE/EN-11B

EE-3 (Spanish version)       EE/EN-12

EE-4                         EE/EN-13

EE-4 (Spanish version)       EE/EN-16

EE-7                         EE/EN-20

EE-7 (Spanish version)


All remaining paper stock of the prior version of these forms (with the expiration date of either October 31, 2013 or December 31, 2013) should be discarded.  In addition, any electronic versions of these forms should be deleted from wherever they are being stored or posted for use by either claims staff or the public and archived.


2.  Effective immediately, all claims staff must begin using the newly renewed forms that bear the expiration date of “12/31/2016.”


3.  Five of the 19 renewed forms (the EE-1, EE-2, EE-3, EE-4 and EE-7) are posted on the DEEOIC webpage for downloading and submission by members of the public.  Those same forms, plus the remaining 14, are also posted and available for use by claims staff in the “Forms” subfolder in the “Policies and Procedures” folder located on the DEEOIC shared drive.


Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.






Director, Division of Energy Employees

Occupational Illness Compensation


Distribution List No. 1:  Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, District Office Mail & File Sections