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Employment History For Claim Under Energy Employees Occupational Illness Compensation Program Act EE-3 - Official Federal Forms
| Employment History For Claim Under Energy Employees Occupational Illness Compensation Program Act Form. This is a national form and can be used in US Dept Of Labor . |
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Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Program Act U.S. Department of Labor Office of Workers' Compensation Programs Division of Energy Empl oyees Occupational Illness Compensation OMB Control No. 1240-0002 Expiration Date: 10/31/2013 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. Employee's Information (print clearly) 1. Employee's Name (Last, First, Middle Initial) 2. Former Name (e.g. Maiden/Legal Change) 3. Social Security Number (If known) Contact Information for Person Completing this Form (Print clearly) 4. Name (Last, First, Middle Initial) 6. Address (Street, Apt. #, P.O. Box) b. Work: (City, State, ZIP Code) 5. Telephone Number(s) a. Home: ( ( ( ) ) ) - c. Cell/Other: Employee's Work History (provide as much information as known - if necessary attach a separate sheet) In chronological order, , 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. Employer - 1 Start Date: Month Day Year End Date: Month Day Year Facility Name (spell out name) Specific Location (building/site/mine/mill) City/State where worked performed Contractor/sub-contractor or Vendor name(s) Type of Facility/Employer (check one) - Department of Energy Facility - Atomic Weapons Facility - Beryllium Vendor - Unknown - Uranium Miner/Miller/Transporter YES NO Unknown Position Title or Mine/Mill Activity Was a dosimetry badge worn while employed? Work Identification Number Description of Work Duties (describe in detail) If known, provide the Dosimetry Badge Number: 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) Former Worker Program (FWP) Other Medical Surveillance Program Radiation Exposure Screening and Education Program (RESEP) Union Member Other (specify): Other Medical Study Form EE-3 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 Employer - 2 Start Date: Month Day Year End Date: Month Day Year Specific Location (building/site/mine/mill) City/State where worked performed Facility Name (spell out name) Contractor/sub-contractor or Vendor name(s) Type of Facility/Employer (check one) - Department of Energy Facility - Atomic Weapons Facility - Beryllium Vendor - Unknown - Uranium Miner/Miller/Transporter YES NO Unknown Position Title or Mine/Mill Activity Work Identification Number Description of Work Duties (describe in detail) Was a dosimetry badge worn while employed? If known, provide the Dosimetry Badge Number: 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) Former Worker Program (FWP) Other Medical Surveillance Program Radiation Exposure Screening and Education Program (RESEP) Union Member Other (specify): End Date: Month Day Year Specific Location (building/site/mine/mill) Month Other Medical Study Employer - 3 Start Date: Day Year Facility Name (spell out name) City/State where worked performed Contractor/sub-contractor or Vendor name(s) Type of Facility/Employer (check one) - Department of Energy Facility - Atomic Weapons Facility - Beryllium Vendor - Unknown - Uranium Miner/Miller/Transporter YES NO Unknown Position Title or Mine/Mill Activity Work Identification Number Description of Work Duties (describe in detail) Was a dosimetry badge worn while employed? If known, provide the Dosimetry Badge Number: 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) Former Worker Program (FWP) Other Medical Surveillance Program Radiation Exposure Screening and Education Program (RESEP) Union Member Other (specify): Other Medical Study Resource Center Date Stamp 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) Page 2 Form EE-3 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com 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 loc
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