If you have a disability (a substantially limiting physical or mental impairment), please contact our office 

for information about the kinds of help available, such as communication assistance (alternate formats 

or sign language interpretation), accommodations and modification.

OMB Control No: 1240-0002 EE-11A 

Expiration Date: 05/31/2025 September 2021 

Page 1 

U.S. DEPARTMENT OF LABOR Office of Workers’ Compensation Programs

Division of Energy Employees Occupational 

Illness Compensation 

DOL DEEOIC Central Mail Room

P.O. Box 8306 

London, KY 40742-8306

Case ID Number: 

Response requested

 First Request

 Second Request 

 Final Request

Dear

This letter is in regard to your claim under Part E of the Energy Employees Occupational 

Illness Compensation Program Act (EEOICPA). Your claim has been accepted for the 

following illness(es): 

As such, you may be eligible for a monetary award for permanent impairment caused by 

the accepted illness(es). 

 “Whole body impairment” (or “impairment”) is a percentage rating that represents 

the extent of impairment of a person based on the organ(s) and or system(s) affected by 

the accepted illness(es). The percentage of impairment reflects how severely your 

accepted illness(es) affect your body as a whole. The available monetary benefit is 

$2,500 for every percentage point, up to a maximum monetary award of $250,000 under 

Part E. 

An impairment rating must be performed by an appropriate physician once your accepted 

illness has reached maximum medical improvement, meaning that it is unlikely to 

improve with additional treatment. In order for a physician to be considered able to 

perform impairment evaluations under EEOICPA, the physician must hold a valid 

medical license and Board certification (or eligibility) in an appropriate field of expertise. 

The physician must also be certified by the American Board of Independent Medical 

Examiners or the International Academy of Independent Medical Evaluators, or possess 

the requisite professional experience and medical work background in interpreting the 

American Medical Association’s Guides to the Evaluation of Permanent Impairment 

(AMA’s Guides) to provide such ratings. 

The impairment evaluation must be well-reasoned and performed in accordance with the 

Fifth edition of the AMA’s Guides, and include references to the pages and tables used in 

arriving at the impairment rating. 

Name 

Street 

City, State, Zip

 :
OMB Control No: 1240-0002 EE-11A 

Expiration Date: 05/31/2025 September 2021 

Page 2 

If you believe you may qualify and wish to claim impairment benefits, please complete 

the enclosed Form EN-11A and be sure to provide the following information: 

x Check “YES” to indicate that you are seeking impairment benefits.

x Check one of the two options to indicate who you would like to perform your

impairment evaluation. If you decide to select your own physician to perform the

impairment evaluation, the physician must demonstrate that he or she is qualified

as noted above. For example, the physician may submit a statement identifying

his/her specific expertise and knowledge of the AMA’s Guides (i.e., years

performing ratings, experience in rating the given condition/body part).

If you elect not to pursue an impairment claim at this time, please check “NO” on Form 

EN-11A and we will not further develop the issue. Also, if this letter is marked above as 

a “Final Request” and we do not hear from you, we will also not develop this issue 

further. However, you retain the right to pursue an impairment claim in the future simply 

by notifying us in writing and sending it to the address at the bottom of the enclosed 

Form EN-11A. 

We would appreciate receiving your written response within 30 days. If you have any 

questions regarding this letter or impairment benefits in general, please do not hesitate to 

contact me. You may call me at . 

Sincerely, 

Enc: Pamphlet, “How Do I qualify for an Impairment Award”

EN-11A 

Name 

Title 

Office
OMB Control No: 1240-0002 EE-11A 

Expiration Date: 05/31/2025 September 2021 

Page 3 

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 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 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. (4) 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 15 minutes 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 this collection is required to 

obtain EEOICPA benefits (20 CFR 30.505). 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/EN-11A. Do not 

submit the completed form to this address. 
OMB Control No: 1240-0002 EN-11A 

Expiration Date: 05/31/2025 September 2021 

Case ID Number: 

Employee Name: 

Impairment Benefits Response Form 

 YES, I wish to pursue a claim for impairment benefits for my accepted illness(es). 

If you checked YES above, you must check one of the two options below and provide the 

necessary information: 

 I want to have DEEOIC arrange for a qualified physician, known as a Contract 

Medical Consultant (CMC), to perform my impairment evaluation. 

 I want to select my own qualified physician to perform my impairment 

evaluation. The physician’s name, address and phone number is: 

Physician Name:____________________________________ 

Address: __________________________________________ 

___________________________________________________ 

Phone No:( )____ ___________ ______________ 

 NO, I am not pursuing impairment benefits at this time. I understand that I can file 

for impairment benefits in the future by submitting a signed statement to that effect to the 

district office. 

Signature (Required) 

 

Signature Date 

Mail EN-11A to: U.S. Department of Labor 

 OWCP/DEEOIC 

 P.O. Box 8306 

 London, KY 40742-8306 

Or you may fax it to: