Employment History For A Claim
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Employment History for a Claim Under
U.S. Department of Labor
the Energy Employees Occupational
Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation Program Act
Illness Compensation
Note: Please read the instructions on page 3 first and provide as much information as possible. Do not
OMB Control No. 1240-0002
write in the shaded areas. Sign and date the bottom of page 2.
Expiration Date: 12/31/2016
Employee’s Information
(print clearly)
1. Employee’s Name
2. Former Name
3. Social Security Number
(Last, First, Middle Initial)
(e.g. Maiden/Legal Change)
(If known)
Contact Information for Person Completing this Form
(Print clearly)
4. Name
5. Telephone Number(s)
(Last, First, Middle Initial)
(
)
-
a. Home:
6. Address
(Street, Apt. #, P.O. Box)
(
)
-
b. Work:
(City, State, ZIP Code)
(
)
-
c. Cell/Other:
Employee’s Work History
(provide as much information as known - if necessary attach a separate sheet)
starting w ith the m ost recent period of em ploym ent
In chronological order,
, provide the complete work history of the employee named above.
Provide as much identifying information as known concerning the name of the employer and location (city & state) where the employee performed
the work. If you require additional space to explain or clarify a point, attach a signed supplemental statement to this form.
Employer - 1
Start Date:
End Date:
Month
Day
Year
Month
Day
Year
Facility Name (spell out name)
Specific Location (building/site/mine/mill)
City/State where worked performed
Contractor/sub-contractor or Vendor name(s)
Type of Facility/Employer (check one)
- Department of Energy Facility
- Beryllium Vendor
- Unknown
- Atomic Weapons Facility
- Uranium Miner/Miller/Transporter
Position Title or Mine/Mill Activity
Was a dosimetry badge worn while employed?
YES
NO
Unknown
Work Identification Number
If known, provide the Dosimetry Badge Number:
Description of Work Duties (describe in detail)
Describe or list the work conditions/exposures you believe caused or contributed to the claimed work illness(es) at this facility
Indicate whether the employee participated in any employer health programs or unions at this facility (check all that apply)
Former Worker Program (FWP)
Radiation Exposure Screening and Education Program (RESEP)
Other Medical Study
Other Medical Surveillance Program
Union Member
Other (specify):
Form EE-3
Page 1
April 2013
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