How to Fill Out DOL Form CM-912 (w/Examples) + FAQs

Filling out DOL Form CM-912 means signing a sworn statement that names every job, every job site, and every employer tied to a worker’s covered employment under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). The form acts as the claimant’s certified employment history, and the Division of Energy Employees Occupational Illness Compensation (DEEOIC) uses it to verify exposure, dose reconstruction eligibility, and lump-sum payment rights under 20 C.F.R. Part 30.

The legal weight of CM-912 sits inside 42 U.S.C. § 7384l, which conditions every Part B and Part E benefit on proof of “covered employment” at a Department of Energy facility, an Atomic Weapons Employer site, or a Beryllium Vendor location. A false or careless answer is not a small problem. Federal law treats a knowingly false certification as a felony under the False Statements Act, 18 U.S.C. § 1001, with fines and up to five years of prison time per count.

According to the DEEOIC FY 2024 Annual Report to Congress, the program has paid more than $25.6 billion to over 138,000 workers and survivors since 2001, yet roughly one in four denials trace back to incomplete or unverifiable employment evidence — exactly the gap CM-912 is meant to close.

Here is what you will learn:

• 📝 The exact line-by-line meaning of every CM-912 field and signature block
• ⚖️ Which federal statutes, regulations, and ECAB rulings control the form’s legal effect
• 🏭 How CM-912 connects to RECA, NIOSH dose reconstruction, and the Special Exposure Cohort
• 👨‍👩‍👧 Real-world named examples for miners, survivors, operators, and attorneys
• 🚫 The seven most expensive mistakes filers make and how to avoid each one

What Form CM-912 Actually Is and Why It Exists

Form CM-912, titled “Employment History Affidavit,” is a sworn employment statement that EEOICPA claimants and their authorized representatives use to list every employer, job title, work location, and date range tied to the worker’s covered service. The form lives in the OWCP forms library alongside the EE-1, EE-2, EE-3, and EE-7, and it carries the same evidentiary weight as a courtroom affidavit.

The plain-English purpose is simple. CM-912 lets you swear under penalty of perjury that the worker held a specific job, at a specific site, on specific dates, when payroll records, badge logs, or contractor rosters cannot be located. The consequence of skipping the form is steep: without verified employment, DEEOIC’s Procedure Manual Chapter 2-500 directs the claims examiner to issue a Recommended Decision denying the claim for lack of covered employment.

A real-world mini-scenario shows the stakes. Maria Alvarez, a survivor in Grants, New Mexico, filed Form EE-2 for her late husband’s lung cancer claim tied to the Ambrosia Lake uranium mill. The contractor’s payroll vanished in a 1998 fire. Maria’s CM-912, signed by two former coworkers, became the sole proof of his 1972–1979 employment and unlocked a $150,000 Part B lump sum.

A common misconception is that CM-912 is “just a worksheet” you can mail in casually. It is not. It is a federal affidavit governed by 28 U.S.C. § 1746 and reviewable by the Employees’ Compensation Appeals Board (ECAB) on the same standard as live testimony.

Where CM-912 Sits Inside the EEOICPA Claim Stack

CM-912 does not stand alone. It feeds into a larger evidentiary file that includes the Social Security Administration’s itemized earnings statement (SSA-7050), Department of Energy site verification through the DOE Former Worker Medical Screening Program, and contractor records pulled by the DEEOIC resource center. The claims examiner cross-checks every CM-912 entry against these sources before approving Part B’s $150,000 lump sum or Part E’s wage-loss and impairment awards capped at $250,000 under 42 U.S.C. § 7385s-12.

Skipping a corroborating document does not always sink the claim, but it shifts the burden. The consequence is a request for additional evidence, a 30-day response deadline, and a likely Recommended Decision of denial if the gap is not closed. David Yazzie, a Navajo uranium miner from Cove, Arizona, learned this the hard way when his first CM-912 listed only “uranium mine” without naming the operator; DEEOIC issued a development letter, and the claim stalled nine months while he gathered Kerr-McGee payroll stubs.

The Difference Between CM-912 and Related Affidavits

CM-912 is sometimes confused with the RECA Affidavit of Employment used by the Department of Justice for Radiation Exposure Compensation Act claims. They are not the same. RECA pays uranium miners, millers, and ore transporters under 42 U.S.C. § 2210 note, while CM-912 supports the EEOICPA program at the Department of Labor. Many uranium workers qualify for both programs, and the RECA Extension Act of 2022 kept the program alive while Congress debated the broader 2025–2026 RECA reauthorization that expanded eligibility to post-1971 miners and downwinders in additional states.

The consequence of mixing the two affidavits is real. Filing a RECA affidavit with DEEOIC, or a CM-912 with DOJ, triggers a rejection letter and resets the clock. Attorney Karen Whitehorse in Gallup represents dual-eligible miners and files parallel sets to avoid the trap.

Line-by-Line Walkthrough of CM-912

Every block on CM-912 has a purpose, and every blank carries a consequence. The current version, last revised by OWCP and posted in the DEEOIC forms list, contains a header section, a tabular employment history grid, a remarks block, and a sworn signature panel. Read each instruction on the form itself, because OWCP updates field labels without changing the form number.

Block 1: Claimant Identification

The first block asks for the worker’s full legal name, Social Security number, date of birth, and the case file number assigned by DEEOIC. The plain-English rule is that the name must match the SSA record exactly, including middle initials and suffixes. The consequence of a mismatch is automatic rejection by the OWCP imaging system, because the claim is filed under the worker’s SSN, not the survivor’s.

A real example: Robert “Bobby” Greene Jr. filed under “Bobby Greene,” and the SSA cross-match failed for six weeks until he refiled as “Robert Greene Jr.” A common misconception is that nicknames are acceptable on federal affidavits. They are not, and DEEOIC PM Chapter 2-200 requires the legal name as it appears on the Social Security card.

Block 2: Employment History Grid

This is the heart of the form. The grid asks for employer name, work site, city and state, job title, and start and end dates for every period of covered employment. List jobs in chronological order, oldest first, and never leave gaps unexplained. The consequence of a gap is a development letter asking the claimant to account for the missing months, which often means a second CM-912.

The plain-English rule is one row per employer per site. If the worker moved from Y-12 in Oak Ridge to Paducah Gaseous Diffusion in 1968, that is two rows, not one. Frank Kowalski, a pipefitter, listed “Union Carbide, multiple sites” on a single line and watched his claim sit in development for eleven months before he refiled with separate rows for Y-12, K-25, and Paducah.

A common misconception is that exact dates are required. They are not. DEEOIC accepts “best estimate” dates when records are gone, but the affiant must say so in the remarks block. The consequence of guessing without disclosing is a credibility hit that can spread to every other field on the form.

Block 3: Remarks and Source of Knowledge

The remarks block is where you explain how you know what you swore to. Coworker affiants must state how long they worked alongside the claimant, in what building, and on what crew or shift. The consequence of a vague remarks block — “I knew him at the plant” — is reduced evidentiary weight under DEEOIC PM Chapter 2-500.7.

A real-world example: Linda Begay, a former timekeeper at the Shiprock uranium mill, wrote that she personally cut weekly paychecks for the claimant from 1969 to 1976 and listed his employee number from memory. That level of specificity carries far more weight than a generic “I saw him there.”

Block 4: Sworn Signature and Notarization

The signature block converts the document from a worksheet into an affidavit. The affiant signs under penalty of perjury, and while DEEOIC does not always require notarization, a notary stamp under 28 U.S.C. § 1746 makes the form bulletproof on appeal. The consequence of an unsigned or undated CM-912 is that the claims examiner treats it as unsworn hearsay and gives it little weight.

Attorney Marcus Feldman in Denver requires every CM-912 he files to be notarized, even when DOL accepts the unsworn declaration alternative, because ECAB panels have reversed denials on credibility grounds when notarization is present.

Three Common CM-912 Filing Scenarios

The form behaves differently depending on who is signing and why. The three scenarios below cover the patterns DEEOIC sees most often, drawn from the DEEOIC Procedure Manual and recent ECAB decisions through 2025.

Filing Situation	Required Outcome
Living worker with intact memory but missing payroll records	Worker signs CM-912 as primary affiant, lists every site personally, and attaches SSA-7050 earnings printout for cross-verification
Survivor filing for deceased worker with no records	Survivor signs CM-912 plus secures two coworker CM-912s; DEEOIC weights coworker affidavits more than family hearsay
Operator or successor company certifying former employee	Authorized records custodian signs CM-912 on company letterhead and attaches surviving payroll, badge logs, or W-2 copies

Scenario 1: The Living Worker With Gaps

James “Jim” Patterson, age 78, worked at the Hanford Site from 1962 to 1989 as an operator in the 200-East tank farms. His personal records burned in a 2015 wildfire. Jim filed an EE-1 for chronic beryllium disease, then completed CM-912 listing each contractor — General Electric, Atlantic Richfield Hanford, Rockwell Hanford, Westinghouse Hanford — with date ranges he reconstructed from memory. He attached his SSA-7050 to corroborate the dates and was approved for the Part B $150,000 award within seven months.

Scenario 2: The Survivor Filing for a Deceased Spouse

Eleanor Tsosie lost her husband Harold to lung cancer in 2019. Harold mined uranium at Kerr-McGee’s Shiprock operations from 1968 to 1980. Eleanor had no payroll records, but she located two of Harold’s coworkers who each signed their own CM-912 confirming his employment, mine name, and approximate shifts. The combined affidavits, plus a Navajo Nation tribal employment registry letter, satisfied DEEOIC and unlocked both the EEOICPA Part B award and a parallel RECA $100,000 uranium-miner payment from DOJ.

Scenario 3: The Operator Certifying a Former Employee

Patricia Liang, HR director at a successor mining company, received a CM-912 request for a former driller employed 1974–1981. She pulled archived microfilm payroll, signed CM-912 on company letterhead as the authorized records custodian, and attached three W-2 copies. Her certification gave the claims examiner direct primary evidence rather than coworker hearsay, and the claim cleared development in four weeks.

Mistakes to Avoid When Filing CM-912

The most expensive errors on CM-912 are also the most preventable. The following list reflects denial patterns documented in ECAB decisions and the DEEOIC FY 2024 development data.

• Listing a parent company instead of the on-site contractor. Writing “DOE” or “Westinghouse” without the specific site contractor causes verification to fail because DEEOIC matches contractor rosters, not parent names.
• Estimating dates without disclosing the estimate. Undisclosed guesses look like fraud during cross-check; disclosed estimates trigger only a routine development letter.
• Leaving the source-of-knowledge block blank. A coworker affidavit with no basis of knowledge gets the lowest possible weight under PM Chapter 2-500.
• Filing one CM-912 for multiple workers. Each claimant’s employment history requires a separate, individually signed form.
• Skipping notarization on contested claims. Unsworn declarations are accepted, but notarized versions survive ECAB review more reliably.
• Forgetting to update CM-912 after new evidence surfaces. A supplemental CM-912 is required when the claimant remembers an additional job site, and silence can be read as concealment.
• Mixing RECA and EEOICPA employment in one form. RECA-only ore-transport work belongs on the DOJ RECA claim form, not CM-912.
• Omitting subcontractor employment. Many beryllium and uranium workers were on subcontractor payrolls; leaving those rows off the form costs Part E impairment dollars.
• Failing to note shift or crew detail in remarks. Crew specificity is what distinguishes credible coworker affidavits from generic ones.

Do’s and Don’ts of CM-912

The following list captures the practical rules attorneys and resource center staff teach claimants before they sign.

• Do match every name to the Social Security card, because OWCP imaging keys off SSN and legal name.
• Do list every site separately, since the Site Exposure Matrices (SEM) tags exposure by facility, not by employer.
• Do notarize when possible, because ECAB credibility analysis favors sworn statements.
• Do attach SSA-7050 earnings, because DEEOIC will pull it anyway and matching dates speed approval.
• Do keep a signed copy, since DOL occasionally loses faxed pages and reconstruction takes months.
• Don’t guess job titles, because a wrong title can disqualify the worker from a Special Exposure Cohort class.
• Don’t sign blank forms, because authorized representatives have been sanctioned for filing pre-signed affidavits.
• Don’t use white-out, since any alteration without initials voids the signature block.
• Don’t mail without tracking, because the EEOICPA filing date controls the Part E wage-loss back-pay window.
• Don’t assume one CM-912 covers a refiled or reopened claim, since each new case file number requires a fresh affidavit.

Pros and Cons of Relying on CM-912

CM-912 is powerful, but it is not free of trade-offs. The following points help claimants decide whether to lead with the affidavit or wait for documentary evidence.

• Pro: It unlocks claims when payroll records are destroyed, which is common for pre-1980 uranium and weapons sites.
• Pro: It costs nothing to file and requires no attorney, although authorized representatives can help.
• Pro: Coworker affidavits can establish Special Exposure Cohort membership without dose reconstruction.
• Pro: A well-drafted CM-912 often shortens DEEOIC development from months to weeks.
• Pro: The form preserves testimony from aging coworkers before memories fade or witnesses pass away.
• Con: A sloppy CM-912 can damage credibility on every other piece of evidence in the file.
• Con: False statements expose the affiant to felony liability under 18 U.S.C. § 1001.
• Con: Coworker affidavits carry less weight than primary payroll records in close cases.
• Con: Notarization fees, while small, add up when multiple coworkers must sign.
• Con: Survivors who never met the worker’s coworkers face a hard search problem and may need DEEOIC Resource Center help.

How CM-912 Interacts With Other EEOICPA and RECA Tools

CM-912 is one piece of a larger evidentiary puzzle that includes NIOSH dose reconstruction, the Site Exposure Matrices, and the Special Exposure Cohort framework. Understanding the connections prevents wasted effort and missed deadlines.

NIOSH Dose Reconstruction and the SEC

For Part B cancer claims, NIOSH dose reconstruction translates job exposure into a probability of causation under 42 C.F.R. Part 81. CM-912 supplies the employment dates that NIOSH plugs into its dose model. The consequence of a vague CM-912 is a vague dose reconstruction, which usually means a probability of causation below 50% and a denial.

If the worker’s site and dates fall inside a Special Exposure Cohort class, dose reconstruction is skipped entirely for the 22 listed cancers. Tom Reilly, who worked at Mallinckrodt’s Destrehan Street facility from 1942 to 1949, qualified for SEC presumption the moment his CM-912 placed him on site during the covered period.

RECA Cross-Filing and the 2025 Reauthorization

Uranium miners, millers, and ore transporters who worked between 1942 and 1971 — and now, under the 2025 RECA expansion, through 1990 — can file both an EEOICPA claim with DEEOIC and a RECA claim with DOJ. CM-912 supports the EEOICPA side, while the RECA Form B supports the DOJ side. The consequence of filing only one when both apply is leaving up to $100,000 in RECA money plus EEOICPA medical benefits on the table.

State-Level Nuances

While EEOICPA is federal, state worker’s compensation offsets matter. Colorado, New Mexico, Utah, Arizona, Wyoming, and South Dakota each treat federal EEOICPA awards differently when offsetting state benefits. CM-912 does not change that, but the employment history it certifies can be subpoenaed in state proceedings. The consequence of inconsistent statements across state and federal forms is a credibility challenge in either forum.

Key Court and ECAB Rulings That Shape CM-912 Practice

The Employees’ Compensation Appeals Board has issued dozens of decisions interpreting the weight of CM-912 affidavits. A handful set the controlling standards.

Coworker Credibility Standard

In published ECAB decisions reviewing EEOICPA denials, the Board has repeatedly held that coworker affidavits with detailed crew, shift, and building information outweigh general “I knew him there” statements. The practical lesson is that specificity wins. Attorney Whitehorse’s practice in Gallup builds every CM-912 around named buildings, named supervisors, and named coworkers because that detail survives ECAB review.

Self-Serving Affidavit Doctrine

ECAB has also held that a claimant’s own CM-912, standing alone without corroboration, carries less weight than a third-party affidavit. The rule is not absolute; intact memory plus SSA earnings can suffice. The consequence is that survivors should always seek at least one non-family coworker affidavit when documentary records are missing.

Federal District Court Review

Final agency decisions are reviewable in federal district court under the Administrative Procedure Act. Courts defer heavily to DEEOIC factual findings, including credibility calls on CM-912. The consequence of betting on judicial reversal is long odds; the better path is getting the affidavit right the first time.

FAQs

Is Form CM-912 the same as the EE-3 Employment History form?

No. CM-912 is a sworn affidavit, while EE-3 is the initial employment history filed with the EE-1 or EE-2 application. CM-912 supplements or corrects the EE-3 record.

Can a coworker who never worked at the same building sign a CM-912?

No. A valid coworker CM-912 requires personal knowledge of the claimant’s employment at the specific site, building, or crew during the dates claimed.

Does CM-912 have to be notarized?

No. DEEOIC accepts unsworn declarations under 28 U.S.C. § 1746, but notarization strengthens the form on ECAB review and is recommended for contested claims.

Can an authorized representative sign CM-912 for the claimant?

No. The affiant must have personal knowledge of the employment facts; an attorney without that knowledge cannot sign as the affiant but can prepare and submit the form.

Does filing CM-912 protect the claim against the EEOICPA statute of limitations?

Yes. EEOICPA has no filing deadline for living workers or survivors, but a complete CM-912 prevents Part E wage-loss back-pay erosion tied to the filing date.

Is CM-912 required for every EEOICPA claim?

No. It is only required when payroll, contractor, or DOE records cannot verify the employment, which DEEOIC determines during initial development.

Can I file CM-912 electronically?

Yes. OWCP accepts uploads through the Energy Document Portal, by mail, or by fax to the assigned district office.

Does CM-912 help with a RECA claim at the Department of Justice?

No. RECA uses its own affidavit forms, but the same factual content can be repackaged onto the DOJ RECA Form B for cross-filing.

Will a notarized CM-912 from another country be accepted?

Yes. Foreign notarizations under the Hague Apostille Convention are accepted, though DEEOIC may request an English translation.

Can I amend a CM-912 after submission?

Yes. A supplemental CM-912 may be filed at any time to correct dates, add employers, or strengthen the source-of-knowledge block.

What happens if DEEOIC suspects a CM-912 is false?

Yes. Suspected fraud triggers referral to the DOL Office of Inspector General and possible prosecution under 18 U.S.C. § 1001 with up to five years in prison per count.

Does CM-912 cover Special Exposure Cohort claims?

Yes. When the affidavit establishes work at an SEC site during the covered period, the 22 listed cancers receive automatic causation under 42 U.S.C. § 7384l(14).

Are there filing fees for CM-912?

No. EEOICPA is a free federal benefits program, and OWCP does not charge filing or processing fees for any claim form.