Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act U.S. Department of Labor Office of Workers’ Compensation Programs Division of Energy Empl oyees Occupational Illness Compensation Note: Please read the instructions on page 3 first and provide as much information as possible. Do not write in the shaded areas. Sign and date the bottom of page 2. OMB Control No. 1240-0002 Expiration Date: 10/31/2013 Employee’s Information (print clearly) 1. Employee’s Name (Last, First, Middle Initial) 2. Former Name (e.g. Maiden/Legal Change) 3. Social Security Number (If known) Contact Information for Person Completing this Form (Print clearly) 4. Name (Last, First, Middle Initial) 5. Telephone Number(s) a. Home: ( ) - b. Work: ( ) - c. Cell/Other: ( ) - 6. Address (Street, Apt. #, P.O. Box) (City, State, ZIP Code) Employee’s Work History (provide as much information as known - if necessary attach a separate sheet) 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 Facility Name (spell out name) Specific Location (building/site/mine/mill) Contractor/sub-contractor or Vendor name(s) Day Year City/State where worked performed Type of Facility/Employer (check one) - Department of Energy Facility - Beryllium Vendor - Atomic Weapons Facility - Uranium Miner/Miller/Transporter - Unknown Position Title or Mine/Mill Activity Was a dosimetry badge worn while employed? Work Identification Number YES NO Unknown 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 Surveillance Program Union Member Other Medical Study Other (specify): Page 1 Form EE-3 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com Employer - 2 Start Date: End Date: Month Day Year Month Facility Name (spell out name) Specific Location (building/site/mine/mill) Contractor/sub-contractor or Vendor name(s) Day Year Type of Facility/Employer (check one) City/State where worked performed - Department of Energy Facility Position Title or Mine/Mill Activity - Beryllium Vendor - Atomic Weapons Facility - Uranium Miner/Miller/Transporter Was a dosimetry badge worn while employed? Work Identification Number YES - Unknown NO Unknown 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) Other Medical Surveillance Program Employer - 3 Radiation Exposure Screening and Education Program (RESEP) Union Member Other (specify): Start Date: Other Medical Study End Date: Month Day Year Month Facility Name (spell out name) Specific Location (building/site/mine/mill) Contractor/sub-contractor or Vendor name(s) Day Year Type of Facility/Employer (check one) City/State where worked performed - Department of Energy Facility Position Title or Mine/Mill Activity Work Identification Number - Beryllium Vendor - Atomic Weapons Facility - Uranium Miner/Miller/Transporter Was a dosimetry badge worn while employed? YES NO - Unknown Unknown 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) Other Medical Surveillance Program Radiation Exposure Screening and Education Program (RESEP) Union Member Other (specify): Declaration of the Person Completing this Form Other Medical Study 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) Page 2 Form EE-3 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com 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 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. Page 3 Form EE-3 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com