Instructions for Completing Form EE-3
This form is used to gather information regarding an employee’s work history for a claim filed under the Energy Employees Occupational Illness
Compensation Program Act. List all periods of employment and provide as much information as known for each period of employment. If you
require additional space, attach a supplemental statement to this form. You may use as many copies of Form EE-3 as necessary in order to
provide a complete employment history for the employee.
Beginning with the most recent period of employment and working backward, list the period of employment for each job held.
Identify the name of the facility the employee worked at for the listed period. Spell out any initials used to describe the facility.
Provide any useful descriptive information about where the work was performed at the listed facility, such as building/site numbers or plant
names. Spell out any initials used to describe the location.
City/State where worked performed
Indicate the city and state where the listed facility was located.
Contractor/sub-contractor or Vendor name
Provide the name of the specific employer the employee worked for at the listed facility. Spell out any initials used to describe the employer.
Check the box that identifies the type of facility that best describes the employee’s work situation.
Identify the employee’s position title or Mine/Mill activity (Uranium Miner, Miller, or Ore Transporter)
Indicate whether or not the deceased employee wore a dosimetry badge while working at the listed facility. If known, provide the badge
identification number.
Work Identification Number
If known, provide the work identification number for the listed period of employment.
Description of Work Duties
Provide a brief, but detailed, description of the work activities performed during the listed period of employment.
Describe or list the work conditions/exposures you believe caused or contributed to the claimed work illness(es)
Provide a brief, but detailed, description of the factors believed to have caused or contributed to the claimed illness(es) at the listed facility.
Indicate whether the employee participated in any employer health programs or was a member of a union
Check the box or boxes indicating whether the employee participated in any employer health programs or unions at the listed facility.
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees Occupational
Illness Compensation Program Act (42 USC 7384
et seq
.) (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.
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 1 hour per response, including time
for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information.
The obligation to respond to the collection is required to obtain EEOICPA benefits (20 CFR 30.111, 30.112. 30.113). Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them 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-3. Do not submit the completed form to this address.
Form EE-3
