FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 3-0700 Post-Award Administration 

 Table of Contents. . . . . . . . i 09/09 09-09 

 1 Purpose and Scope. . . . . . . . 1 09/09 09-09 

 2 Authority. . . . . . . . . . . . 1 09/09 09-09 

 3 Claims Examiner Responsibilities 1 09/09 09-09 

 4 National Office Responsibilities 2 09/09 09-09 

Exhibits 

 1 Form EE-12, Letter Enclosing 

 EN-12 Questionnaire. . . . . . 09/09 09-09 

 2 Form EE-13, Letter from 

 National Office With Blank 

 EN-13. . . . . . . . . . . . . 09/09 09-09 

EEOICPA Tr. No. 09-09 

September 2009 

i 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

1. Purpose and Scope. This chapter outlines the actions 

Claims Examiners (CE) take on Part E cases after a claim has 

been approved for benefits. This chapter also describes the 

procedures used by the National Office (NO) to ensure that 

payment of medical benefits to covered Part E employees is fully 

coordinated with any state workers’ compensation benefits 

received by those employees or their survivors. 

2. Authority. Section 7385s-11(a) requires that compensation 

to an individual under Part E be coordinated with state workers’ 

compensation benefits, other than medical benefits and benefits 

for vocational rehabilitation, that the individual has received 

for the same covered illness. The Director of DEEOIC has been 

delegated the authority to request information from state 

workers’ compensation authorities concerning state workers’ 

compensation benefits that covered Part E employees receive. 

3. Claims Examiner Responsibilities. The CE sends a Form EE12 letter, accompanied by Form EN-12 enclosure (Exhibit 1), to 

each covered Part E employee who receives medical benefits under 

Part E for a covered illness. These forms are sent on the oneyear anniversary of the latest award of any type of Part E 

benefits, and every year thereafter in which the employee 

continues to receive medical benefits. The employee must 

complete and return the EN-12 questionnaire within 30 days. 

If the employee has not responded after 30 days, the CE attempts 

to verify the employee’s contact information in the case file 

and send another Form EE/EN-12 and provide the employee with an 

additional 30 days to in which to respond. 

Upon receipt of a completed Form EN-12 from an employee, the CE 

reviews the employee’s responses and takes the appropriate 

action as noted below. 

a. Change of Address. If the employee lists a new address 

or telephone number, the CE notes the new information in 

the case file. The CE also ensures that the new contact 

information is reflected in the ECMS. 

b. Treatment Concerns. If the employee identifies 

concerns about the treatment that he or she is receiving 

for a covered illness, the CE acknowledges these concerns 

by letter and advises that they are being referred to the 

appropriate person for further action. 

EEOICPA Tr. No. 09-09 

September 2009 

1 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

3. Claims Examiner Responsibilities. (Continued) 

c. Additional Impairment or Wage Loss. If the employee 

indicates that he or she wishes to claim additional Part E 

compensation due to increased permanent impairment as a 

result of an accepted covered illness, or additional 

compensation for another calendar year of qualifying wageloss, the CE follows established procedures for 

facilitating these claims. 

d. State Workers’ Compensation. If the employee 

indicates that he or she has filed for or received state 

workers’ compensation benefits after the receipt of an 

award of Part E benefits, the CE ensures that all of the 

information requested concerning the state workers’ 

compensation benefits filed for or received has been 

provided. 

e. Tort Awards or Settlements. If the employee indicates 

that, since receiving an award of benefits under Part E, he 

or she has received a tort award or settlement (other than 

for a claim for workers’ compensation) in connection with a 

lawsuit alleging exposure to a toxic substance for which 

the Part E award was received, the CE ensures that all of 

the information requested concerning the tort award or 

settlement has been provided. 

4. National Office Responsibilities. At the beginning of each 

fiscal year, the NO Fiscal Officer sends a Form EN-13 

information request (Exhibit 2) to each state’s workers’ 

compensation authority advising of the requirement under EEOICPA 

that any state workers’ compensation benefits received by a 

covered Part E employee for an accepted covered illness must be 

coordinated with Part E benefits received for that same illness, 

and requesting information about workers’ compensation benefits 

paid to employees who have been awarded Part E benefits. 

Upon receipt from the states, the NO Fiscal Officer sends copies 

of the information gained to each District Office Fiscal Officer 

for comparison against the information contained in the claims 

files for listed individuals. 

a. Initial Requests. Form EE-13 lists employees who 

worked at DOE facilities in the state in question whose 

claims for compensation under Part E were accepted during 

EEOICPA Tr. No. 09-09 

September 2009 

2 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

4. National Office Responsibilities. (Continued) 

the 12 months preceding issuance of the Form EE-13. For 

each employee, the list contains the following information: 

(1) Name(s) of the claimant(s); 

(2) Whether the claimant is the employee or the 

employee’s survivor; 

(3) Social Security number of the employee; 

(4) Employee’s accepted medical condition; and 

(5) Date the claimant’s eligibility for Part E 

benefits began. 

For each employee listed, the state agency is asked to 

provide information about state workers’ compensation 

claim(s) that have been filed on behalf of the same worker, 

including the name(s) of the claimant(s), whether the claim 

was accepted, and if so, the medical condition accepted and 

the effective date of the award. 

b. Subsequent Requests. Form EE-13 also contains a second 

list of employees for whom information has already been 

requested by a prior Form EE-13. For each employee on the 

second list, the state agency will be asked to indicate 

whether any information provided in response to the initial 

request has changed. 

EEOICPA Tr. No. 09-09 

September 2009 

3 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

FORM EE-12 LETTER ENCLOSING EN-12 QUESTIONNAIRE

Dear Claimant Name: 

The information requested in the attached enclosure is required in connection 

with your claim for benefits under the Energy Employees Occupational Illness 

Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. § 7384 et seq. This 

information will be used to ensure that we have current contact information 

for you, and to verify that you are eligible to continue receiving medical or 

other benefits for your accepted conditions as shown above. The form also 

provides you with an opportunity to provide us with any concerns regarding 

your current medical treatment for your accepted conditions, and in some 

cases, to initiate review of potential additional impairment or wage-loss 

benefits. 

Please completely answer all questions and return the enclosure within 30 

days of the date of this letter. Pub. L. 100-503 provides that the 

statements on the enclosure and other information in your claim file may be 

verified through computer matches. OWCP may also request that you submit 

additional factual evidence to support your statements, if needed.

READ ALL INSTRUCTIONS CAREFULLY BEFORE FILLING OUT THE ENCLOSURE. YOU MUST 

ANSWER ALL OF THE QUESTIONS. IF THE QUESTION DOES NOT APPLY TO YOUR CLAIM, 

STATE “NOT APPLICABLE (N/A)” OR “NONE.”

If you need more space to fully answer any of the questions, use another 

sheet of paper with your name and claim number at the top. Sign and date 

each extra sheet.

When you have completed the enclosure, sign it and return it to the address 

shown at the top of this letter. Your signature certifies that you have 

supplied all information requested by the enclosure. If you have any 

questions about completing the enclosure, call me at (111) 222-3333 or write 

to me at the above address.

Sincerely,

Claims Examiner

Enclosure: EN-12

OMB No. 1215-0197 EE-12 Page 1

Expiration Date: February 2008

EEOICPA Tr. No. 09-09 

September 2009 

Page 1 of 5 

Exhibit 1 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

NOTICE TO RECIPIENT

Public reporting burden for this collection of information is estimated to 

average 20 minutes per response, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, 

and completing and reviewing the collection of information. 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, OWCP, Room S3524, 200 Constitution Avenue, NW, 

Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. 

Persons are not required to complete this form unless it displays a currently 

valid OMB number.

 

EEOICPA Tr. No. 09-09 

September 2009 

Page 2 of 5 

Exhibit 1 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

File Number: Claimant:

SECTION A – CURRENT CONTACT INFORMATION

If you have moved or have a different mailing address from the one shown at 

the top of the first page of the accompanying letter, provide the current 

information in the space provided below. (Do not complete if the information 

is correct). Also, please provide a current telephone number.

Name:__________________________________________

Address:_______________________________________

City and State:________________________________

Zip Code:______________________________________

Telephone Number:______________________________

SECTION B – CURRENT MEDICAL CONDITION

Do you have any concerns regarding treatment for your accepted medical 

conditions as shown on the letter that accompanied this form?

Yes or No: ________

If yes, please describe your concerns: 

_____________________________________________________________________________

_____________________________________________________________________________

____________________________________________________________________

__________________________________________________________________________

Do you wish to claim additional compensation for impairment due to your 

accepted condition? Yes or No: _______

Do you wish to claim additional compensation for wage-loss? (Wage-loss 

benefits are payable only if the wages were lost prior to your regular Social 

Security retirement age.) Yes or No: _______

Would you like for your claims examiner to contact you by telephone regarding 

your concerns? Yes or No: ________

EEOICPA Tr. No. 09-09 

September 2009 

Page 3 of 5 

Exhibit 1 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

File Number: Claimant:

SECTION C – STATE WORKERS’ COMPENSATION

1. Have you filed for and/or received any state workers’ compensation for 

your accepted condition(s) since you were awarded EEOICPA benefits? Yes or 

No: __________

2. If you answered “Yes,” please tell us the following information:

Date of filing:___________________________________________

State in which you filed:_________________________________ 

Name of employer, insurer or state that paid:________________________

Amount of monetary benefits received: $____________________

Type of benefits (disability, impairment, etc.):________________

List the same information for any other state workers’ compensation received 

after being awarded EEOICPA benefits on an extra sheet.

SECTION D – TORT AWARDS OR SETTLEMENTS

1. Since you were awarded EEOICPA benefits, have you received any 

settlement or award from a claim or tort suit (other than a claim for 

workers’ compensation) against a third party in connection with an exposure

to a toxic substance for which you received EEOICPA benefits? Yes or No: 

__________

2. If you answered “Yes,” please tell us the following information:

Date of award or settlement:_________________________________________

Party or parties involved:___________________________________________

Type of suit or settlement:__________________________________________

Amount of award or settlement: $______________________________

List any other tort awards or settlements below or on an extra sheet.

 

EEOICPA Tr. No. 09-09 

September 2009 

Page 4 of 5 

Exhibit 1 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

SECTION E – CERTIFICATION

I know that anyone who fraudulently conceals or fails to report information 

that would have an effect on benefits, or who makes a false statement or 

misrepresentation of a material fact in claiming a payment or benefit under 

the Energy Employees Occupational Illness Compensation Program Act may be 

subject to criminal prosecution, from which a fine and/or imprisonment may 

result.

I understand that I must immediately report to OWCP any state workers’ 

compensation benefits or tort awards/settlements I receive.

I certify that all the statements made in response to questions on this 

enclosure are true, complete and correct to the best of my knowledge and 

belief. I have placed “Not Applicable (N/A)” or “None” next to those 

questions that do not apply to me or my claim.

_____________________________________________________________

Signature Date

 

EEOICPA Tr. No. 09-09 

September 2009 

Page 5 of 5 

Exhibit 1 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

 

Date Telephone number

 

STATE WORKERS’ COMPENSATION AGENCY

STREET ADDRESS

CITY, STATE ZIP CODE

The information requested in the attachments is required in connection with 

claims for benefits under the Energy Employees Occupational Illness 

Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. § 7384 et seq. Section 

§ 7385s-11 of the EEOICPA provides for coordination of benefits with respect 

to state workers’ compensation as follows:

(a) IN GENERAL.—An individual who has been awarded compensation under 

this part, and who has also received benefits from a State workers’ 

compensation system by reason of the same covered illness, shall 

receive compensation specified in this part reduced by the amount of 

any workers’ compensation benefits, other than medical benefits and 

benefits for vocational rehabilitation, that the individual has 

received under the State workers’ compensation system by reason of the 

covered illness, after deducting the reasonable costs, as determined by 

the Secretary, of obtaining those benefits under the State workers’ 

compensation system.

* * *

(c) INFORMATION.—Notwithstanding any other provision of law, each 

State workers’ compensation authority shall, upon request of the 

Secretary, provide to the Secretary on a quarterly basis information 

concerning workers’ compensation benefits received by any covered DOE 

contractor employee entitled to compensation or benefits under this 

part, which shall include the name, Social Security number, and nature 

and amount of workers’ compensation benefits for each such employee for 

which the request was made.

The first attached list contains the names of employees who worked at 

facilities in your state on whose behalf a claim under 

OMB No. 1215-0197 EE-13 Page 1

Expiration Date: 08/31/2010 February 2007

EEOICPA Tr. No. 09-09 

September 2009 

Page 1 of 3 

Exhibit 2 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

Part E of EEOICPA has been accepted during the last year. The second list 

contains the names of employees for whom we have made a previous inquiry. 

For each employee, we have listed the name(s) of the claimant(s), whether the 

claimant is the employee or a survivor, the Social Security Number of the 

employee, the accepted medical condition, and the date eligibility began. 

For each entry on the first list, please indicate whether or not a state 

workers’ compensation claim has been filed on behalf of that same worker, the 

name(s) of the claimant, and whether the claim has been accepted, and if 

accepted, the accepted medical condition, the effective date of the award, 

and the amount of the award. For each entry on the second list, please 

indicate whether there has been any change since the last time information 

was provided.

 

If you have questions about this request, please contact XXXXXXX XXXXXXXX at 

(111) 222-3333.

Thank you for your assistance.

 

Sincerely,

Director

Director, Division of Energy Employees 

 Occupational Illness Compensation

Enclosure: EN-13

NOTICE TO RECIPIENT

Public reporting burden for this collection of information is estimated to 

average 16 hours per response, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, 

and completing and reviewing the collection of information. 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, OWCP, Room S3524, 200 Constitution Avenue, NW, 

Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. 

Persons are not required to complete this form unless it displays a currently 

valid OMB number.

 

EE-13 Page 2

 

EEOICPA Tr. No. 09-09 

September 2009 

Page 2 of 3 

Exhibit 2 

SUPERCEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0700 

Part 3 – Fiscal Post-Award Administration 

________________________________________________________________ 

Employee Name Claimant Name E or S Employee SSN Accepted Condition Effective Date

 

EN-13 Page 1

EEOICPA Tr. No. 09-09 

September 2009 

Page 3 of 3 

Exhibit 2 

SUPERCEDED