82 FR 7863 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; Energy Employees Occupational Illness Compensation Program Act Forms

DEPARTMENT OF LABOR
Office of the Secretary

Federal Register Volume 82, Issue 13 (January 23, 2017)

Page Range		7863-7864
FR Document		2017-01404

The Department of Labor is submitting the Office of Workers' Compensation Programs (OWCP) sponsored information collection request (ICR) titled, ``Energy Employees Occupational Illness Compensation Program Act Forms,'' to the Office of Management and Budget (OMB) for review and approval for continued use, without change, in accordance with the Paperwork Reduction Act (PRA) of 1995. Public comments on the ICR are invited.

Federal Register, Volume 82 Issue 13 (Monday, January 23, 2017)

[Federal Register Volume 82, Number 13 (Monday, January 23, 2017)]
[Notices]
[Pages 7863-7864]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2017-01404]



[[Page 7863]]

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DEPARTMENT OF LABOR

Office of the Secretary


Agency Information Collection Activities; Submission for OMB 
Review; Comment Request; Energy Employees Occupational Illness 
Compensation Program Act Forms

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: The Department of Labor is submitting the Office of Workers' 
Compensation Programs (OWCP) sponsored information collection request 
(ICR) titled, ``Energy Employees Occupational Illness Compensation 
Program Act Forms,'' to the Office of Management and Budget (OMB) for 
review and approval for continued use, without change, in accordance 
with the Paperwork Reduction Act (PRA) of 1995. Public comments on the 
ICR are invited.

DATES: The OMB will consider all written comments that agency receives 
on or before February 22, 2017.

ADDRESSES: A copy of this ICR with applicable supporting documentation; 
including a description of the likely respondents, proposed frequency 
of response, and estimated total burden may be obtained free of charge 
from the RegInfo.gov Web site at http://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=201610-1240-003 or by contacting Michel Smyth by 
telephone at 202-693-4129 (this is not a toll-free number) or sending 
an email to [email protected].
    Submit comments about this request to the Office of Information and 
Regulatory Affairs, Attn: OMB Desk Officer for DOL-OWCP, Office of 
Management and Budget, Room 10235, 725 17th Street NW., Washington, DC 
20503, Fax: 202-395-6881 (this is not a toll-free number), email: 
[email protected]. Commenters are encouraged, but not 
required, to send a courtesy copy of any comments to the U.S. 
Department of Labor-OASAM, Office of the Chief Information Officer, 
Attn: Information Management Program, Room N1301, 200 Constitution 
Avenue NW., Washington, DC 20210, email: [email protected].

FOR FURTHER INFORMATION CONTACT: Michel Smyth by telephone at 202-693-
4129 (this is not a toll-free number) or by email at 
[email protected].

    Authority: 44 U.S.C. 3507(a)(1)(D).


SUPPLEMENTARY INFORMATION: This ICR seeks to maintain PRA authorization 
for the Energy Employees Occupational Illness Compensation Program Act 
Forms information collection. The OWCP is the primary agency 
responsible for administering the Energy Employees Occupational Illness 
Compensation Program Act of 2000, as amended (EEOICPA) (42 U.S.C. 7384 
et seq.). The EEOICPA provides for timely payment of compensation to 
covered employees who sustained either occupational or otherwise 
covered illnesses incurred in the performance of duty for the 
Department of Energy (DOE) and certain of its contractors and 
subcontractors and, where applicable, survivors of such employees. The 
EEOICPA sets forth eligibility criteria for claimants for compensation 
under EEOICPA parts B and E and outlines the various elements of 
compensation payable from the Energy Employees Occupational Illness 
Compensation Fund.
    Regulations 20 CFR 30.100, -.101, -.102, -.103, -.111, -.112, 
-.113, -.114, -.206, -.207, -.212, -.213, -.214, -.215, -.221, -.222, 
-.226, -.231, -.232, -.415, -.416, -.417, -.505, -.620, -.806, -.905, 
and -.907 implementing the EEOICPA contain information collection 
requirements covered by this ICR. The OWCP also uses this ICR to obtain 
PRA authorization to implement the information collection requirement 
found at 42 U.S.C. 7385s-11.
    More specifically, the OWCP uses forms covered by this ICR to 
determine a claimant's eligibility for EEOICPA compensation and 
responses are required to obtain or retain benefits. The information 
collections in this ICR collect demographic, factual, and medical 
information needed to determine entitlement to EEOICPA benefits. Before 
the OWCP can pay benefits, the case file must contain medical and 
employment evidence showing the claimant's eligibility. The various 
collections covered by this ICR and the purpose of each are as follows:
    Form EE-1--A living current or former employee completes the form 
to file a claim under parts B and/or E. The form requests information 
about the illness or illnesses being claimed and information about tort 
suits, settlements, or awards in litigation; State workers' 
compensation benefits; and fraud convictions that affect entitlement. 
This form is also available in Spanish. (20 CFR 30.100, -.103, -.505, 
and -.620.)
    Form EE-2--The survivor of a deceased employee uses the form to 
file a claim under parts B and/or E. The form requests information 
regarding both the survivor and the deceased employee. The form also 
requests information about illnesses, tort suits, settlements, or 
awards in litigation; State workers' compensation benefits; and fraud 
convictions that affect entitlement. This form is also available in 
Spanish. (20 CFR 30.101, -.103, -.505, and -.620.)
    Form EE-3--The form gathers information about the employee's work 
history. This form is also available in Spanish. (20 CFR 30.103, -.111, 
-.113, -.114, -.206, -.212, -.214, -.221, and -.231.)
    Form EE-4--The employee or survivor uses the form to support the 
claimed employment history by affidavit. This form is also available in 
Spanish. (20 CFR 30.103, -.111, -.113, -.114, -.206, -.212, -.214, 
-.221, and -.231.)
    Form EE-5A--A claimant must provide supplemental employment 
evidence to substantiate periods of unverified employment. There is no 
standard form or format for the submission of this information. For 
purposes of identification only, this requirement has been designated 
Form EE-5A. (20 CFR 30.112.)
    Form EE-5B--A current or former DOE contractor provides information 
to substantiate periods of unverified employment. There is no standard 
form or format for the submission of the information. For purposes of 
identification only, this requirement has been designated Form EE-5B. 
(20 CFR 30.106.)
    Form EE-7--The OWCP uses this form to inform an employee, survivor, 
or physician of the medical evidence needed to establish a diagnosis of 
an occupational illness under part B or a covered illness under part E. 
This form is also available in Spanish. (20 CFR 30.103, -.207, -.215, 
-.222, -.232(a) and (b), -.415, -.416, and -.417.)
    Form EE-7A--A claimant is required to provide information about 
when an injury, illness, or disability is sustained because of an 
occupational illness under part B or a covered illness under part E. 
There is no standard form or format for the submission of this medical 
information. For purposes of identification only, this requirement has 
been designated Form EE-7A. (20 CFR 30.207, -.215, -.222, -.226, and 
-.232(c).)
    Form EE-8--The OWCP sends this letter with enclosure EN-8 to a 
claimant to obtain information about an employee's smoking history when 
lung cancer due to radiation is claimed. Department of Health and Human 
Services (HHS) guidelines require the OWCP to ask for information 
regarding the employee's smoking history before the OWCP can determine 
the probability of causation for radiogenic lung cancer. (20 CFR 
30.213.)
    Form EE-9--The OWCP sends this letter with enclosure EN-9 to a 
claimant

[[Page 7864]]

to obtain information concerning the race or ethnicity of the employee 
when radiogenic skin cancer is claimed. HHS guidelines require the OWCP 
to ask for this particular information regarding the employee's race/
ethnicity before the OWCP can determine the probability of causation 
for radiogenic skin cancer. (20 CFR 30.213.)
    Form EE-10--A covered part E employee who has received an award for 
wage-loss and/or impairment due to a covered illness uses this form to 
provide information needed to support a claim for an additional award 
for a subsequent calendar year of wage-loss and/or any additional 
impairment. (20 CFR 30.102, -.103, and -.505.)
    Form EE-11A--The OWCP sends this letter about impairment benefits 
under part E with enclosure EN-11A to a claimant to obtain medical 
evidence needed to support an initial award for permanent impairment 
due to an accepted covered illness. (20 CFR 30.905 and -.907.)
    Form EE-11B--The OWCP sends this letter with enclosure EE-11B to a 
part E claimant to obtain the factual and medical evidence necessary to 
support an initial award for wage-loss benefits due to an accepted 
covered illness. (20 CFR 30.806.)
    Form EE-12--The OWCP sends this letter with enclosure EN-12 to a 
covered part B or E employee receiving medical benefits to collect 
updated information about settlements or awards in litigation and State 
workers' compensation benefits that affect continuing entitlement. (20 
CFR 30.100 and -.505.)
    Form EE-13--The OWCP sends this letter with enclosure EN-13 to a 
State workers' compensation authority to identify covered part E 
employees receiving medical benefits who have also been awarded State 
workers' compensation for their covered illnesses. (42 U.S.C. 7385s-
11.)
    Form EE-16--The OWCP sends this letter with enclosure EN-16 to a 
claimant to verify/obtain updated information about tort suits, 
settlements, or awards in litigation; State workers' compensation 
benefits; and fraud convictions that affect entitlement immediately 
prior to issuance of a recommended decision on the claim. (20 CFR 
30.505 and -.620.)
    Form EE-20--The OWCP sends this letter with enclosure EN-20 to a 
claimant to obtain financial information necessary to pay approved 
claims under part B or E. (20 CFR 30.505 and -.620.)
    This information collection is subject to the PRA. A Federal agency 
generally cannot conduct or sponsor a collection of information, and 
the public is generally not required to respond to an information 
collection, unless it is approved by the OMB under the PRA and displays 
a currently valid OMB Control Number. In addition, notwithstanding any 
other provisions of law, no person shall generally be subject to 
penalty for failing to comply with a collection of information that 
does not display a valid Control Number. See 5 CFR 1320.5(a) and 
1320.6. The DOL obtains OMB approval for this information collection 
under Control Number 1240-0002. The DOL notes that existing information 
collection requirements submitted to the OMB receive a month-to-month 
extension while they undergo review. For additional substantive 
information about this ICR, see the related notice published in the 
Federal Register on October 28, 2016 (81 FR 75163).
    Interested parties are encouraged to send comments to the OMB, 
Office of Information and Regulatory Affairs at the address shown in 
the ADDRESSES section within 30 days of publication of this notice in 
the Federal Register. In order to help ensure appropriate 
consideration, comments should mention OMB Control Number 1240-0002. 
The OMB is particularly interested in comments that:
     Evaluate whether the proposed collection of information is 
necessary for the proper performance of the functions of the agency, 
including whether the information will have practical utility;
     Evaluate the accuracy of the agency's estimate of the 
burden of the proposed collection of information, including the 
validity of the methodology and assumptions used;
     Enhance the quality, utility, and clarity of the 
information to be collected; and
     Minimize the burden of the collection of information on 
those who are to respond, including through the use of appropriate 
automated, electronic, mechanical, or other technological collection 
techniques or other forms of information technology, e.g., permitting 
electronic submission of responses.
    Agency: DOL-OWCP.
    Title of Collection: Energy Employees Occupational Illness 
Compensation Program Act Forms.
    OMB Control Number: 1240-0002.
    Affected Public: Individuals or households; Private Sector--
businesses or other for-profits.
    Total Estimated Number of Respondents: 57,277.
    Total Estimated Number of Responses: 60,621.
    Total Estimated Time Burden: 20,539 hours.
    Total Estimated Annual Other Costs Burden: $27,800.

    Dated: January 13, 2017.
Michel Smyth,
Departmental Clearance Officer.
[FR Doc. 2017-01404 Filed 1-19-17; 8:45 am]
 BILLING CODE 4510-CR-P

Federal Register / Vol. 82, No. 13 / Monday, January 23, 2017 / Notices 7863

DEPARTMENT OF LABOR OWCP is the primary agency entitlement. This form is also available
responsible for administering the Energy in Spanish. (20 CFR 30.101, –.103,
Office of the Secretary Employees Occupational Illness –.505, and –.620.)
Compensation Program Act of 2000, as Form EE–3—The form gathers
Agency Information Collection amended (EEOICPA) (42 U.S.C. 7384 et information about the employee’s work
Activities; Submission for OMB seq.). The EEOICPA provides for timely history. This form is also available in
Review; Comment Request; Energy payment of compensation to covered Spanish. (20 CFR 30.103, –.111, –.113,
Employees Occupational Illness employees who sustained either –.114, –.206, –.212, –.214, –.221, and
Compensation Program Act Forms occupational or otherwise covered –.231.)
illnesses incurred in the performance of Form EE–4—The employee or
ACTION: Notice. duty for the Department of Energy survivor uses the form to support the
SUMMARY: The Department of Labor is (DOE) and certain of its contractors and claimed employment history by
submitting the Office of Workers’ subcontractors and, where applicable, affidavit. This form is also available in
Compensation Programs (OWCP) survivors of such employees. The Spanish. (20 CFR 30.103, –.111, –.113,
sponsored information collection EEOICPA sets forth eligibility criteria –.114, –.206, –.212, –.214, –.221, and
request (ICR) titled, ‘‘Energy Employees for claimants for compensation under –.231.)
EEOICPA parts B and E and outlines the Form EE–5A—A claimant must
Occupational Illness Compensation
various elements of compensation provide supplemental employment
Program Act Forms,’’ to the Office of
payable from the Energy Employees evidence to substantiate periods of
Management and Budget (OMB) for
Occupational Illness Compensation unverified employment. There is no
review and approval for continued use,
Fund. standard form or format for the
without change, in accordance with the
Regulations 20 CFR 30.100, –.101, submission of this information. For
Paperwork Reduction Act (PRA) of
–.102, –.103, –.111, –.112, –.113, –.114, purposes of identification only, this
1995. Public comments on the ICR are
–.206, –.207, –.212, –.213, –.214, –.215, requirement has been designated Form
invited.
–.221, –.222, –.226, –.231, –.232, –.415, EE–5A. (20 CFR 30.112.)
DATES: The OMB will consider all Form EE–5B—A current or former
–.416, –.417, –.505, –.620, –.806, –.905,
written comments that agency receives and –.907 implementing the EEOICPA DOE contractor provides information to
on or before February 22, 2017. contain information collection substantiate periods of unverified
ADDRESSES: A copy of this ICR with requirements covered by this ICR. The employment. There is no standard form
applicable supporting documentation; OWCP also uses this ICR to obtain PRA or format for the submission of the
including a description of the likely authorization to implement the information. For purposes of
respondents, proposed frequency of information collection requirement identification only, this requirement has
response, and estimated total burden found at 42 U.S.C. 7385s–11. been designated Form EE–5B. (20 CFR
may be obtained free of charge from the More specifically, the OWCP uses 30.106.)
RegInfo.gov Web site at http:// forms covered by this ICR to determine Form EE–7—The OWCP uses this
www.reginfo.gov/public/do/PRAView a claimant’s eligibility for EEOICPA form to inform an employee, survivor,
ICR?ref_nbr=201610-1240-003 or by compensation and responses are or physician of the medical evidence
contacting Michel Smyth by telephone required to obtain or retain benefits. The needed to establish a diagnosis of an
at 202–693–4129 (this is not a toll-free information collections in this ICR occupational illness under part B or a
number) or sending an email to DOL_ collect demographic, factual, and covered illness under part E. This form
PRA_PUBLIC@dol.gov. medical information needed to is also available in Spanish. (20 CFR
Submit comments about this request determine entitlement to EEOICPA 30.103, –.207, –.215, –.222, –.232(a) and
to the Office of Information and benefits. Before the OWCP can pay (b), –.415, –.416, and –.417.)
Regulatory Affairs, Attn: OMB Desk benefits, the case file must contain Form EE–7A—A claimant is required
Officer for DOL–OWCP, Office of medical and employment evidence to provide information about when an
Management and Budget, Room 10235, showing the claimant’s eligibility. The injury, illness, or disability is sustained
725 17th Street NW., Washington, DC various collections covered by this ICR because of an occupational illness under
20503, Fax: 202–395–6881 (this is not a and the purpose of each are as follows: part B or a covered illness under part E.
toll-free number), email: OIRA_ Form EE–1—A living current or There is no standard form or format for
submission@omb.eop.gov. Commenters former employee completes the form to the submission of this medical
are encouraged, but not required, to file a claim under parts B and/or E. The information. For purposes of
send a courtesy copy of any comments form requests information about the identification only, this requirement has
to the U.S. Department of Labor- illness or illnesses being claimed and been designated Form EE–7A. (20 CFR
OASAM, Office of the Chief Information information about tort suits, settlements, 30.207, –.215, –.222, –.226, and
Officer, Attn: Information Management or awards in litigation; State workers’ –.232(c).)
Program, Room N1301, 200 Constitution compensation benefits; and fraud Form EE–8—The OWCP sends this
Avenue NW., Washington, DC 20210, convictions that affect entitlement. This letter with enclosure EN–8 to a claimant
email: DOL_PRA_PUBLIC@dol.gov. form is also available in Spanish. (20 to obtain information about an
FOR FURTHER INFORMATION CONTACT: CFR 30.100, –.103, –.505, and –.620.) employee’s smoking history when lung
Michel Smyth by telephone at 202–693– Form EE–2—The survivor of a cancer due to radiation is claimed.
4129 (this is not a toll-free number) or deceased employee uses the form to file Department of Health and Human
a claim under parts B and/or E. The Services (HHS) guidelines require the
mstockstill on DSK3G9T082PROD with NOTICES

by email at DOL_PRA_PUBLIC@dol.gov.
form requests information regarding OWCP to ask for information regarding
Authority: 44 U.S.C. 3507(a)(1)(D). both the survivor and the deceased the employee’s smoking history before
SUPPLEMENTARY INFORMATION: This ICR employee. The form also requests the OWCP can determine the probability
seeks to maintain PRA authorization for information about illnesses, tort suits, of causation for radiogenic lung cancer.
the Energy Employees Occupational settlements, or awards in litigation; (20 CFR 30.213.)
Illness Compensation Program Act State workers’ compensation benefits; Form EE–9—The OWCP sends this
Forms information collection. The and fraud convictions that affect letter with enclosure EN–9 to a claimant

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Document Created: 2017-01-20 01:30:19
Document Modified: 2017-01-20 01:30:19

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Notices
Action		Notice.
Dates		The OMB will consider all written comments that agency receives on or before February 22, 2017.
Contact		Michel Smyth by telephone at 202-693- 4129 (this is not a toll-free number) or by email at [email protected]
FR Citation		82 FR 7863

82 FR 7863 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; Energy Employees Occupational Illness Compensation Program Act Forms

DEPARTMENT OF LABOROffice of the Secretary

Federal Register Volume 82, Issue 13 (January 23, 2017)

DEPARTMENT OF LABOR
Office of the Secretary