Form EE-3 Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act

Form EE-3 is a U.S. Department of Labor form also known as the "Employment History For A Claim Under The Energy Employees Occupational Illness Compensation Program Act". The latest edition of the form was released in November 1, 2015 and is available for digital filing.

Download a PDF version of the Form EE-3 down below or find it on U.S. Department of Labor Forms website.

ADVERTISEMENT
RESET
SAVE
PRINT
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: 03/31/2020
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
November 2015
Next Page
RESET
SAVE
PRINT
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: 03/31/2020
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
November 2015
Next Page
Employer - 2
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):
Employer - 3
Start Date:
End Date:
Month
Day
Year
Month
Day
Year
Specific Location (building/site/mine/mill)
Facility Name (spell out name)
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):
Declaration of the Person Completing this Form
Resource Center Date Stamp
Any person who knowingly makes any false statement, misrepresentation, concealment of fact of any other act of fraud to obtain
compensation as provided under EEOICPA or who knowingly accepts compensation to which that person is not entitled is subject
to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be
punished by a fine or imprisonment or both. I affirm that the information provided on this form is accurate and true. I also
authorize the Department of Justice, Social Security Administration, any Former Worker Program, union, medical study or
medical surveillance program (or any other person, institution, corporation, or government agency) identified on this form to
furnish any desired information to the U.S. Department of Labor, Office of Workers’ Compensation Programs.
(Signature)
(Date)
Form EE-3
Page 2
November 2016
Next Page
Previous Page
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.
Dates of Employment
Beginning with the most recent period of employment and working backward, list the period of employment for each job held.
Facility Name
Identify the name of the facility the employee worked at for the listed period. Spell out any initials used to describe the facility.
Specific Location
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.
Type of Facility
Check the box that identifies the type of facility that best describes the employee’s work situation.
Position Title
Identify the employee’s position title or Mine/Mill activity (Uranium Miner, Miller, or Ore Transporter)
Dosimetry Badge
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.
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 Occupational
et seq
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 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
Page 3
November 2016
Previous Page

Download Form EE-3 Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act

966 times
Rate
4.3(4.3 / 5) 48 votes
ADVERTISEMENT
Page of 3