Form EE-3 

September 2021

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

Division of Energy Employees Occupational 

Illness Compensation

Employment History for a Claim Under 

the Energy Employees Occupational 

Illness Compensation Program Act

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: 05/31/2025

Employee's Information (print clearly)

3. Social Security Number (if known)

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

(City, State, ZIP Code)

5. Telephone Number(s)

a. Home: ( )

b. Work: ( ) -

-

Contact Information for Person Completing this Form (print clearly)

Type of Facility/Employer (check one)

- Department of Energy Facility

- Atomic Weapons Facility

- Beryllium Vendor

- Uranium Miner/Miller/Transporter

- Unknown

1. Employee's Name (Last, First, Middle Initial) 2. Former Name (e.g. Maiden/Legal Change)

4. Name (Last, First, Middle Initial)

c. Cell/Other: ( ) -

Employee’s Work History (provide as much information as known - if necessary attach a separate sheet)

In chronological order, starting with the most recent period of employment, 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.

Facility Name (spell out name) Specific Location (building/site/mine/mill) City/State where work performed

Contractor/sub-contractor or Vendor name(s)

Position Title or Mine/Mill Activity

Work Identification Number

 Was a dosimetry badge worn while employed? 

 If known, provide the Dosimetry Badge Number:

 Yes No Unknown

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)

 Other Medical Study

 Union Member Other (specify):

 Radiation Exposure Screening and Education Program (RESEP)

 Other Medical Surveillance Program

 Former Worker Program (FWP)

Start Date: Month Day Year Employer - 1 End Date: Month Day Year

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Form EE-3 

September 2021

Declaration of the Person Completing this Form

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) 

Type of Facility/Employer (check one)

- Department of Energy Facility

- Atomic Weapons Facility

- Beryllium Vendor

- Uranium Miner/Miller/Transporter

- Unknown

Start Date: Month Day Year Employer - 2 End Date: Month Day Year

Facility Name (spell out name) Specific Location (building/site/mine/mill) City/State where work performed

Contractor/sub-contractor or Vendor name(s)

Position Title or Mine/Mill Activity

Work Identification Number

 Was a dosimetry badge worn while employed? 

 If known, provide the Dosimetry Badge Number:

 Yes No Unknown

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)

 Other Medical Study

 Union Member Other (specify):

 Radiation Exposure Screening and Education Program (RESEP)

 Other Medical Surveillance Program

 Former Worker Program (FWP)

Type of Facility/Employer (check one)

- Department of Energy Facility

- Atomic Weapons Facility

- Beryllium Vendor

- Uranium Miner/Miller/Transporter

- Unknown

Start Date: Month Day Year Employer - 3 End Date: Month Day Year

Facility Name (spell out name) Specific Location (building/site/mine/mill) City/State where work performed

Contractor/sub-contractor or Vendor name(s)

Position Title or Mine/Mill Activity

Work Identification Number

 Was a dosimetry badge worn while employed? 

 If known, provide the Dosimetry Badge Number:

 Yes No Unknown

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)

 Other Medical Study

 Union Member Other (specify):

 Radiation Exposure Screening and Education Program (RESEP)

 Other Medical Surveillance Program

 Former Worker Program (FWP)

Resource Center Date Stamp

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Form EE-3 

September 2021

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 work 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 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) 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 

displaysa 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.

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