Form Ee-1 - Worker'S Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - U.s. Department Of Labor, Office Of Workers' Compensation Programs Page 2

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Instructions for Completing Form EE-1
Complete all items on the form. If additional space is required to explain or clarify any point, attach a supplemental statement to the
form. If the requested information is not submitted, you should explain the reason(s) for the delay and indicate when the information
will be forthcoming. Submit the completed claim form and all other pertinent documentation to the following address:
DOL DEEOIC Central Mail Room Correspondence
P.O. Box 8306
London, KY 40742-8306
I llness(es) Being Claim ed
Item 8 – Identify the specific physician-diagnosed condition(s) that you claim are work related. Do not list the symptoms (e.g. aches,
pains, cough, wheezing, breathing problems, etc.) associated with the diagnosed condition(s). If you require additional space, attach a
signed supplemental statement to this form.
Item 9 – List the date a physician first diagnosed the claimed condition(s) you listed in Item 8.
Aw ards and Other I nform ation
Question 10 – Mark the appropriate box indicating whether you have filed a civil lawsuit based on exposure to any toxic substance. If
you mark the box for YES, provide copies of all pertinent court documentation.
Question 11- Mark the appropriate box indicating whether you have filed any state workers’ compensation claims in connection with
any condition(s) you claim in Item 8. If you mark the box for YES, provide copies of all pertinent state workers’ compensation
documentation.
Question 12– Mark the appropriate box indicating whether you or another person received a settlement or other type of award from a
lawsuit or a state workers’ compensation claim described in Questions 10 or 11. If you mark the box for YES, provide copies of all
pertinent documentation.
Question 13 - Mark the appropriate box indicating whether or not you have ever pled guilty to or been convicted on any charges
connected to an application for or receipt of federal or state workers’ compensation.
Question 14 – Mark the appropriate box indicating whether you have filed for an award from the Department of Justice (DOJ) under
Section 5 of the Radiation Exposure Compensation Act (RECA). If you mark the box for YES, provide the claim number associated with
that RECA claim in the space provided.
Question 15 – Mark the appropriate box indicating whether you have filed for an award from DOJ under Section 4 of RECA.
Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees
et seq
Occupational Illness Compensation Program Act (42 USC 7384
.) (EEOICPA) is administered by the Office of Workers’
Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their
immediate families. (2) Information received will be used to determine eligibility for, and the amount of, benefits payable under
EEOICPA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal
agencies or private entities that employed the employee to verify statements made, answer questions concerning the status of the claim
and to consider other relevant matters. (4) Information may be disclosed to physicians and other health care providers for use in
providing treatment, performing evaluations for the Office of Workers’ Compensation Programs, and for other purposes related to the
medical management of the claim. (5) Information may be given to Federal, state, and local agencies for law enforcement purposes, to
obtain information relevant to a decision under EEOICPA, to determine whether benefits are being paid properly, including whether
prohibited payments have been made, and, where appropriate, to pursue debt collection actions required or permitted by the Debt
Collection Act. (6) Disclosure of your social security number (SSN) or tax identification number (TIN) is mandatory. We are authorized to
collect your SSN or TIN under Executive Order 9397 (November 22, 1943). Your SSN or TIN, and other information maintained by the
Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes
required or authorized by law. (7) Failure to disclose all requested information may delay the processing of the claim or the payment of
benefits, or may result in an unfavorable decision.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to the information collections on this form unless
it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 17 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and
reviewing the collection of information. You are required to respond to this collection to obtain EEOICPA benefits (20 CFR 30.100(a)).
Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the U.S. Department of Labor, Office of Workers’ Compensation Programs, Room S3524, 200 Constitution Avenue N.W.,
Washington, D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE-1. Do not submit the completed form to this
address.
Form EE-1
Page 2
December 2013
Previous Page

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