3. Social Security Number (If known)

5. Your Telephone Number(s)

U.S. Department of Labor Office of Workers’ Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

Employment History Affidavit for a Claim 

Under the Energy Employees Occupational 

Illness Compensation Program Act

OMB Control No. 1240-0002 

Expiration Date: 05/31/2025

Note: Please read the instruction on page 3 before filling out this form. Please do not write in the shaded areas. 

Sign at the bottom of the second page. This form should not be completed by the person who is claiming 

benefits under EEOICPA. Use as many copies of Form EE-4 as necessary.

Employee’s Information (print clearly)

1. Employee’s Name (Last, First, Middle Initial) 2. Maiden/Former Name

Your Information (print clearly)

4. Your Name (Last, First, Middle Initial)

(City, State, ZIP Code)

6. Your Address (Street, Apt. #, P.O. Box)

a. Home: ( ) -

b. Work: ( ) -

c. Cell/Other: ( ) -

7. Your Relationship to the Employee (Check all that apply)

Work Associate Spouse Son/Daughter Step-child Parent

 Grandparent Friend Neighbor Other:

Employee’s Work History - Use a New Form for Each Period or Place of Employment

Your knowledge of where 

and for whom the 

employee worked

(Provide as much identifying 

information as possible about 

the name of the employer 

and location. Spell out all 

names.)

Facility Name:

Facility Location (City/State):

Building(s):

Contractor or sub-contractor name(s):

Employee’s Occupation 

and Title Occupation: Title:

Dates you know the 

employee worked at 

this facility Month Day Year

Start Date:

Month Day Year

End Date:

If you worked with the 

employee during this 

period, provide the 

following: 

Your position and title:

 

 Dates you worked at this facility:

Month Day Year

To:

Month Day Year

From:

Form EE-4 

Page 1 September 2021
Form EE-4 

Page 2 September 2021

Work History Narrative for This Employment: (Be as specific as possible – if necessary attach a separate sheet)

Describe in detail the type of work the employee performed at this facility. For instance, describe the work processes or work duties the 

employee was engaged in at this facility. Explain how you know of the employee’s presence at this facility and the type of work the employee 

performed. Include any information you believe would be useful in confirming the employment history.

Declaration of the Person Completing this Form Resource Center Date Stamp

Any person who knowingly makes any false statement, misrepresentation, concealment 

of fact or any other act of fraud in a statement to the U.S. government 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.

(Signature) Date
Form EE-4 

Page 3 September 2021

This form is used to affirm the employment history of a living or deceased employee. The EE-4 is an acceptable format for providing an affidavit 

in support of an otherwise unverified work history and can be filled out by anyone with knowledge of an employee’s work history. Use as many 

EE-4 forms as needed. If you require additional space to provide comments, attach a signed supplemental statement.

Form EE-4

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) 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.

Privacy Act 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 30 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 voluntary. 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, 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-4. Do not submit the completed form to this address.

Public Burden Statement