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Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act

Form ID:

OWCP EE-3

Control ID:

OMB Control No: 1240-0002

Expiration date:

Wed, 31 May 2028 - 23:59

Forms

OWCP EE-3: Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act

Note: 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. You also have the option to complete, digitally sign, and submit the form online at https://eclaimant.dol.gov. If you choose to complete your form online, mailing the form is not necessary.