Issue Date: May 5, 2003


Effective Date: May 5, 2003


Expiration Date: May 5, 2003


Subject: Use of Revised EE-5 Employment Verification Form.

Background: The purpose of this bulletin is to introduce a revised EE-5 Employment Verification Form. Compared to the earlier version, the revised EE-5 incorporates many changes that will enable the district offices to more quickly and accurately collect employment data from the Department of Energy (DOE).

References: 20 CFR § 30.105, PM 2-0400.3-4

Purpose: To provide the district offices with a revised EE-5 Employment Verification Form.

Applicability: Claims Examiners, Senior Claims Examiners, All Supervisors, District Directors.


1. The revised EE-5 Employment Verification Sheet replaces all earlier versions. The claims examiner (CE) is to use the revised version in all future instances where employment verification is required by the DOE.

2. The CE is to use established policy and procedure in identifying the appropriate DOE employment verification action site or operation center handling employment verifications for DOE facilities. Refer to PM 2-0400 & Bulletin 02-02.

3. After the CE determines the DOE action site responsible for verifying claimed employment, a cover letter is to be prepared for the attention of the appropriate DOE point of contact (Attachment 1).

4. Attached to the cover letter will be a separate EE-5 Employment Verification Sheet (Attachment 2) for each claimed employer the DOE must comment on. For each EE-5 required, the CE is to complete the Employee Information section providing the employee name, SSN, claimed employer name and the facility where employment is alleged to have occurred. The form allows the DOE to complete the Employee Information section in situations where they possess information on the employee that was not provided in the claimed work history. The CE is to also include a copy of the EE-1 or 2 Claim for Benefits and EE-3 Employment History. The entire package is to be mailed directly to the responsible DOE point of contact.

5. The CE is not to release an EE-5 unless the claimant has specified employment at a DOE facility covered by the appropriate DOE action site. To make this determination, the CE is to compare claimed employment locations to the list of DOE facilities maintained on the OWA web site or in the Federal register. Because the claimant is asked to identify the entire work history of an alleged employee, it may be difficult to ascertain whether or not the location of employment duties occurred at a DOE facility. As such, the CE must be careful to identify any claimed employment that may potentially be linked to a covered facility. If the claimant has identified an employer without a clear location of where employment occurred and the CE suspects that it may have been at a DOE facility, clarification must be obtained. The CE may suspect employment at a DOE facility, if the claimant indicates employment occurred at a location where work was performed in conjunction with atomic weapons, radioactive materials or DOE weapon programs.

6. #9; If the CE determines that clarification is required, a letter should be prepared advising the claimant that employment must be claimed at a covered facility type such as a DOE facility. The claimant is to be asked to specify the name of the DOE facility where employment is alleged to have occurred. The CE can refer the claimant to the list of covered facilities provided in the Federal Register or online at the DOE webpage. A period of thirty days is to be granted to the claimant to provide evidence establishing claimed employment at a covered DOE facility. If after thirty days the claimant has not responded, or provided evidence that does not identify a claimed DOE facility, the CE can conclude that the claimed employment is not eligible for consideration under EEOICPA. The conclusion of the CE to exclude the employer from consideration is to be noted in the Statement of Facts prepared by the CE in the Recommended Decision.

7. Upon receipt of an EE-5 from the DOE action site, the CE should review it for completeness. The DOE is responsible for marking one of the three options provided on the form and attaching any relevant information. In addition, the DOE representative completing the form must certify its accuracy. Any form that does not meet these requirements is to be returned to the DOE action site for completion. In this situation, the CE should input code DE in ECMS effective the date of resubmission.

8. Once DOE has marked one of the options and signed the EE-5, it is considered the final comment from DOE in regard to claimed employment. No further employment verification information should be sought from the DOE after a completed EE-5 has been received by the CE.

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


Director, Division of Energy Employees

Occupational Illness Compensation

Distribution: 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.)





(District Office Address)




(DOE Operations Address)

To Whom It May Concern:

A claim for benefits under the Energy Employees’ Occupational Illness Compensation Program Act (EEOICPA) has been submitted with respect to the employee named above, claiming employment at a Department of Energy facility. He or she is claiming that employment for the Department of Energy or one of its contractors or subcontractors has contributed to a covered illness. Your facility has been identified as having possession of or access to records that can verify the accuracy of claimed employment.

Included as an attachment to this cover letter is a copy of the claimant’s EE-1 or EE-2 Claim for Benefits, the EE-3 Employment History and an EE-5 Employment Verification Sheet.

I have reviewed the claimed work history provided by the claimant and have determined that your site is responsible for verifying the accuracy of a claimed period of employment. Marked on the attached EE-5 is the name of the employee, employee SSN, employer name and the facility where employment is alleged to have occurred.

Please conduct a reasonable search of existing records to determine whether the claimed employment history is accurate. Verify any period of employment including any that is not noted on this form or by the claimant on the EE-3 Employment History. You may make as many copies of the Employment Verification Sheet as necessary.

Please return the completed Employment Verification Sheets to the address provided above. If you have received this request in error or if you have any other concerns, please feel free to contact me directly at ***-***-**** or fax ***-***-****.



Claims Examiner


EE-1/2 Claim for Benefits

EE-3 Employment History