How to Fill Out DOL Form EE-4 (w/Examples) + FAQs

Form EE-4 is the Employment History Affidavit used by the U.S. Department of Labor’s Division of Energy Employees Occupational Illness Compensation (DEEOIC) to confirm a worker’s job history at a covered Department of Energy (DOE) site, Atomic Weapons Employer (AWE) facility, or Beryllium Vendor location. You fill it out by listing the worker’s employer, job title, work location, and dates of employment, then signing under penalty of perjury so DEEOIC can corroborate exposure under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

The form solves a recurring evidence gap. Many covered facilities lost or destroyed personnel records decades ago, and the Oak Ridge Institute for Science and Education (ORISE) corporate verification database often returns “no record found.” When that happens, the controlling regulation at 20 CFR §30.111 shifts the burden to the claimant to produce alternative proof, and a properly executed EE-4 from a co-worker is one of the few accepted substitutes.

A wrong, vague, or unsigned EE-4 can sink a claim worth six figures. According to the DEEOIC’s FY 2024 Annual Report to Congress, the program has paid more than $25 billion in compensation and medical benefits since 2001, with an average Part B lump-sum award of $150,000, yet roughly 22% of initial claims are denied for insufficient employment evidence.

Here is what you will learn in this guide:

📋 The exact line-by-line method to complete every box on EE-4 without triggering a Remand or Recommended Denial
⚖️ How federal regulations under 20 CFR Part 30 treat affidavit evidence versus payroll records
🏭 Site-specific tips for Hanford, Oak Ridge, Paducah, Portsmouth, Savannah River, Rocky Flats, and Nevada Test Site claimants
🧑‍⚖️ Three named-person examples showing winning and losing EE-4 strategies
🚫 Seven costly mistakes that delay or destroy otherwise valid Part B and Part E claims

What Form EE-4 Actually Is

Form EE-4, officially titled “Employment History Affidavit for Claims Under the Energy Employees Occupational Illness Compensation Program Act,” is a sworn statement that documents a covered worker’s employment at a DOE, AWE, or Beryllium Vendor site. The current version is DOL Form EE-4 (Rev. Oct 2020) and is downloadable from the DOL forms library. It is two pages, requires notarization or a witnessed signature, and supplements (it does not replace) the Form EE-3 Employment History submitted by the claimant.

The form exists because Congress, through 42 U.S.C. §7384l, defined a “covered employee” by where and when the person worked, not just by job title. DEEOIC must therefore verify location and dates before authorizing dose reconstruction by the National Institute for Occupational Safety and Health (NIOSH). When ORISE confirmation fails, EE-4 affidavits become the bridge that lets the claim move forward to the NIOSH Division of Compensation Analysis and Support.

The consequence of skipping EE-4 when records are missing is severe. Claims Examiners (CEs) issue a “Development Letter” under EEOICPA Procedure Manual Chapter 2-500 giving you 30 days to respond, and silence triggers a Recommended Decision to deny.

A common misconception is that EE-4 is optional paperwork. It is mandatory whenever the claimant cannot produce W-2s, badge records, union pension statements, or DOE security clearance files that independently prove employment.

Who Signs an EE-4

Two distinct people can sign an EE-4: the claimant (or the survivor) and a co-worker affiant who personally observed the worker on site. The co-worker version carries far more evidentiary weight because it is third-party corroboration, which DEEOIC’s Final Adjudication Branch (FAB) treats as substantial evidence under 20 CFR §30.111(a).

The claimant’s own EE-4 is still useful, especially when the worker is deceased and a surviving spouse is filing under Part B survivor rules. The consequence of submitting only a self-affidavit and no co-worker affidavit is that CEs typically issue a “weight of evidence” finding rejecting the self-statement as self-serving.

For example, Maria Delgado, a survivor of a deceased Paducah Gaseous Diffusion Plant pipefitter, learned this the hard way; her solo EE-4 was rejected, but two affidavits from her late husband’s union brothers reversed the denial on reconsideration.

A frequent misconception is that the co-worker must have worked the same shift. The Procedure Manual only requires the affiant to have personally observed the worker performing duties at the covered site during overlapping employment.

When EE-4 Is Required

EE-4 is required whenever the DOE Office of Hearings and Appeals cannot verify employment through the DOE HR Records Center or when ORISE returns a partial match. It is also required when the worker was employed by a subcontractor whose records were destroyed, such as the Mallinckrodt Chemical Works operations from 1942 to 1957.

The consequence of filing late is that the claim sits in “Development Hold” status, and interest does not accrue on any future award. Time matters.

A real example: James “Jim” Whitfield, a former Y-12 security inspector at Oak Ridge, filed his Part E claim in 2019 but waited 14 months to submit EE-4 affidavits, delaying his $250,000 impairment award by more than a year.

The misconception here is that DEEOIC will request EE-4 if it needs it. The CE may ask once, but the burden of production stays on the claimant under 20 CFR §30.114.

Line-by-Line Walkthrough of Form EE-4

The form is divided into six functional zones: claimant identification, employee identification, affiant identification, employment details, narrative description, and signature/notary. Each zone has its own pitfalls.

You can always cross-check the layout against the official PDF posted in the DOL OWCP Forms Library.

Block 1 — Claimant Information

Enter the claimant’s full legal name, the DEEOIC case file number (a 9-digit number that begins with the worker’s Social Security Number stripped of dashes), and the daytime phone number. The case number lives at the top of every letter from the Cleveland, Denver, Jacksonville, or Seattle DEEOIC District Office.

The consequence of mis-keying the case number is automatic mis-routing into the wrong file, which the Office of Inspector General audits have flagged as a recurring source of delay.

For example, Robert Chen, a Hanford radiological control technician, transposed two digits and his EE-4 was indexed to a stranger’s file for 90 days before correction.

A common misconception is that the case number equals the SSN. It is the SSN without dashes, plus a check letter on some files; always copy it directly from a DEEOIC letter.

Block 2 — Employee Information

List the covered worker’s full name, any aliases, date of birth, Social Security Number, and date of death if applicable. Aliases matter at sites with large immigrant workforces such as the Iowa Army Ammunition Plant where surname spellings shifted between hiring records and union cards.

The consequence of omitting an alias is that ORISE searches return “no match” even when records exist under the prior name.

For instance, Anna Kowalczyk-Brown worked at Rocky Flats from 1978 to 1984 under her maiden name Kowalczyk, remarried in 1986, and her DOE badge file would not surface until her affiant listed both names on EE-4.

The misconception is that nicknames are irrelevant. List “Bob” for Robert and “Jim” for James because plant rosters often used informal first names.

Block 3 — Affiant Information

The affiant (the person signing) must list their full name, current address, phone, relationship to the worker, and their own employment dates at the covered facility. The affiant is swearing under penalty of perjury per 18 U.S.C. §1001 that the statements are true.

The consequence of a false statement is criminal liability and automatic claim denial, plus possible referral to the DOL Office of Inspector General.

A real misconception is that family members make the best affiants. They actually make the worst — DEEOIC’s policy under PM Chapter 2-600 discounts affidavits from spouses, children, and parents because of presumed bias.

Block 4 — Employment Details Table

This is the heart of the form. List the employer name (e.g., DuPont, Union Carbide, Bechtel, Fluor, Westinghouse), the DOE/AWE site name (e.g., Savannah River Site, Y-12 National Security Complex), the work location within the site (e.g., 235-F Building, K-25 cascade), the job title, and the exact start and end dates.

The consequence of vague dates like “summer of 1972” is that NIOSH cannot run a dose reconstruction window, and the claim stalls indefinitely.

For example, Carlos Ramirez, a Nevada Test Site driller, originally wrote “early 1960s” and his claim sat for two years until a co-worker produced specific dates of March 1962 through November 1965, which unlocked a $150,000 Part B award.

A misconception is that approximate dates are acceptable. They are not — use the Social Security Earnings Statement to anchor exact quarters when memory fails.

Block 5 — Narrative of Duties and Exposures

Describe what the worker did, what materials they handled (uranium, plutonium, beryllium, thorium, trichloroethylene), and where on site the work occurred. Specificity is everything because Part E requires linkage between a toxic substance and the diagnosed illness under 42 U.S.C. §7385s-4.

The consequence of generic language like “worked with chemicals” is that the Site Exposure Matrices (SEM) database cannot map the toxin to the disease.

For instance, Linda Pierce, a Portsmouth Gaseous Diffusion Plant operator, wrote that she “ran the cascade,” and her CE used SEM to link UF6 exposure to her chronic beryllium disease screening.

The misconception is that you should keep it short. Write 150 to 300 words of concrete detail; vague affidavits lose under FAB precedent decisions.

Block 6 — Signature, Date, and Notary

Sign in blue or black ink, date the signature, and have either a notary public stamp the form or provide a witness signature. EEOICPA accepts unsworn declarations under 28 U.S.C. §1746 when notarization is unavailable.

The consequence of an unsigned EE-4 is automatic rejection — DEEOIC will return the form unprocessed.

A misconception is that an electronic signature works. As of the DEEOIC Bulletin 21-03, wet-ink signatures remain the standard for affidavits, although the ECOMP claimant portal accepts uploaded scans of signed originals.

Three Real-World Scenarios

The following table shows how three common fact patterns play out under DEEOIC review.

Claimant Situation	DEEOIC Outcome
Hanford pipefitter, ORISE confirms employment, claimant submits EE-4 anyway with detailed exposure narrative	Claim accepted in 90 days; EE-4 strengthens Part E causation
Oak Ridge K-25 janitor, ORISE returns no record, claimant submits two co-worker EE-4 affidavits with overlapping dates	Claim accepted under 20 CFR §30.111 substantial-evidence standard
Mallinckrodt uranium worker (1946-1952), records destroyed, only spouse’s EE-4 submitted	Claim denied; spouse affidavit discounted as biased; reconsideration requires non-family affiant

A second scenario table illustrates Part B versus Part E weighting.

Evidence Type	Weight Under DEEOIC Review
ORISE corporate verification letter	Conclusive proof of employment
Two unrelated co-worker EE-4 affidavits	Substantial evidence sufficient to establish covered employment
Single self-affidavit by claimant	Weak; usually requires corroboration
Family member EE-4 only	Discounted under PM Chapter 2-600

A third scenario table covers timing.

Filing Window	Practical Result
EE-4 filed with initial EE-1 or EE-2 claim	Fastest path; average decision in 6 months per DEEOIC performance data
EE-4 filed in response to 30-day Development Letter	Still timely; claim resumes processing
EE-4 filed after Recommended Denial	Treated as reconsideration evidence under 20 CFR §30.319

Site-Specific Filing Tips

Each major DOE complex has its own quirks that show up in EE-4 review.

Hanford Site, Washington

Hanford employed thousands through prime contractors including DuPont, General Electric, Rockwell, and Westinghouse Hanford. List the prime contractor and the specific area (100, 200 East, 200 West, 300, 400, or 1100 Area).

The consequence of writing only “Hanford” is that NIOSH cannot select the correct dose reconstruction protocol from the NIOSH Hanford Site Profile.

For example, Walter Henderson wrote “Hanford site, all areas,” and his dose reconstruction defaulted to the lowest-exposure profile until a co-worker EE-4 specified work in the 200 East tank farms.

The misconception is that all Hanford work was radiological. Construction trades in the 1100 Area had primarily chemical exposures tracked separately in SEM.

Oak Ridge Reservation, Tennessee

Oak Ridge contains three distinct facilities — Y-12, K-25, and X-10 (Oak Ridge National Laboratory) — each with separate employment records and separate dose reconstruction protocols.

The consequence of conflating them is automatic rework by NIOSH and a 6-month delay.

A real example: Dorothy Mason worked at K-25 from 1953 to 1965 but her EE-4 said “Oak Ridge”; her case was reopened only after a former Atomic Trades and Labor Council steward signed a corrected affidavit.

The misconception is that ORNL and Y-12 share records. They do not, and cross-referencing requires separate ORISE queries.

Paducah and Portsmouth Gaseous Diffusion Plants

Both gaseous diffusion plants operated under Union Carbide, Goodyear Atomic, Lockheed Martin, and USEC over different decades. The contractor name on EE-4 must match the era.

The consequence of a contractor mismatch is a Development Letter requesting clarification.

For instance, Earl Bishop listed “USEC” for work he performed in 1978, but USEC did not exist until 1993 — the correct contractor was Union Carbide, and the error delayed his claim by four months.

The misconception is that the parent company name suffices. DEEOIC matches the operating contractor shown in DOE Facility List records.

Rocky Flats, Savannah River, and Nevada Test Site

Rocky Flats plutonium workers should always note Building 771, 776, 707, or 991. Savannah River workers should specify reactor area (C, K, L, P, or R) or separations area (F or H Canyon). Nevada Test Site workers should specify Area 12 (tunnels), Area 25 (NRDS), or above-ground/below-ground test participation.

The consequence of skipping building or area numbers is that the Special Exposure Cohort (SEC) presumption may not apply.

A real example: Ruth Aguilar of Rocky Flats originally wrote “production area” and lost her SEC presumption until an affiant specified Building 771 plutonium recovery between 1969 and 1976.

The misconception is that “trust me, I was there” works. SEC class membership is granted by building and date range, not by site name alone, per the HHS SEC Petitions process.

Mistakes to Avoid

These are the most damaging errors DEEOIC Claims Examiners report.

Using approximate dates. Vague timeframes prevent NIOSH from running dose reconstruction, and the claim stalls under 20 CFR §30.115.
Letting a family member be the only affiant. Spousal and child affidavits are discounted as biased, and the claim usually denies on weight of evidence.
Skipping the notary or 28 U.S.C. §1746 declaration. An unsworn affidavit is treated as a letter, not evidence, and rejected under PM Chapter 2-600.
Writing a generic exposure narrative. Phrases like “worked with chemicals” prevent SEM linkage and kill Part E causation under 42 U.S.C. §7385s-4.
Listing the wrong contractor for the era. Mismatched contractor names trigger Development Letters and 30 to 90 days of delay.
Forgetting the case file number. Mis-routed forms can sit indexed to the wrong file for months, as shown in DOL OIG audit findings.
Submitting only one co-worker affidavit when two are available. A single corroborator is “some evidence”; two unrelated corroborators meet the substantial evidence threshold under 20 CFR §30.111.
Using an electronic signature on the original. Wet-ink signatures remain required per DEEOIC Bulletin guidance.
Failing to upload through ECOMP. Mail submissions add 2 to 3 weeks; the ECOMP portal timestamps receipt instantly.

Do’s and Don’ts

These shortcut rules synthesize a decade of FAB precedent.

Do anchor employment dates with Social Security Earnings records because matching quarters defeats most date challenges.
Do request the worker’s DOE Personnel Records under FOIA before drafting the affidavit so dates align.
Do describe specific buildings, processes, and toxic substances because SEM linkage drives Part E causation.
Do obtain two unrelated co-worker affidavits because the substantial evidence rule rewards corroboration.
Do submit through the ECOMP portal for instant receipt and tracking.
Don’t let a spouse be the sole affiant because biased affidavits lose under PM Chapter 2-600.
Don’t guess at dates because vague entries trigger NIOSH rework.
Don’t skip the notary because unsworn affidavits are not evidence.
Don’t copy another claimant’s narrative because boilerplate language flags as unreliable in FAB review.
Don’t wait for DEEOIC to ask because the burden of production stays with the claimant.

Pros and Cons of Filing EE-4 Early

There are real strategic tradeoffs to filing EE-4 before DEEOIC asks.

Pro — faster claim adjudication because the file is complete on day one and the CE skips the Development Letter cycle.
Pro — locks in affiant testimony before witnesses die, which matters for cohorts now in their 80s and 90s.
Pro — strengthens Part E causation by feeding Site Exposure Matrices immediately.
Pro — gives the Authorized Representative a complete record to argue from at FAB hearing.
Pro — preserves entitlement to interest from the original filing date under 20 CFR §30.505.
Con — locks in dates that later records may contradict, creating impeachment risk.
Con — requires affiant cooperation, which is hard with deceased or estranged former co-workers.
Con — notary fees and travel impose modest out-of-pocket costs.
Con — premature narrative may omit toxins later identified through NIOSH dose reconstruction interviews.
Con — once filed, amendments require explanation and may invite credibility questions.

How DEEOIC Weighs EE-4 Against Other Evidence

DEEOIC follows a hierarchy spelled out in the EEOICPA Procedure Manual and refined by FAB precedent decisions. At the top sit DOE-verified employment records and ORISE corporate verification letters, which are conclusive.

Below that, Social Security Administration earnings records corroborate dates but not site location, so they pair well with EE-4 affidavits that supply the geographic detail SSA cannot.

Below SSA records, two unrelated co-worker EE-4 affidavits with overlapping employment periods constitute substantial evidence under 20 CFR §30.111(a). A single co-worker affidavit is “some evidence” and usually triggers a Development Letter rather than acceptance.

Self-affidavits and family-member affidavits sit at the bottom of the hierarchy and rarely carry a claim alone. The DAR (Document Acquisition Request) process can sometimes recover lost records from the National Personnel Records Center and bypass EE-4 entirely, but it averages 6 to 9 months.

The consequence of misunderstanding the hierarchy is wasted time. Filing only a self-affidavit when two co-workers are available is a tactical error that adds months to the case.

For example, Theodore “Ted” Morrison, a Y-12 machinist, filed only his own EE-4 in 2018, was denied, and won on reconsideration in 2020 only after producing two former International Association of Machinists brothers as affiants.

A misconception is that DEEOIC investigates independently. The CE will run ORISE and DAR, but everything else is on the claimant under 20 CFR §30.114.

Key Entities You Should Know

The EE-4 universe is crowded with agencies, contractors, and unions.

The Department of Labor’s DEEOIC adjudicates claims and pays benefits.
The Department of Energy holds employment and security records and runs the DAR process.
NIOSH performs dose reconstruction for Part B radiation cancers.
The Final Adjudication Branch issues final decisions and hears objections.
The Office of Hearings and Appeals adjudicates Part E impairment disputes when worker advocates request hearings.
ORISE runs the corporate verification database used at intake.
Authorized Representatives, often attorneys or non-attorney advocates, can sign and submit forms on the claimant’s behalf.

The consequence of confusing DOL with DOE is months of misdirected paperwork; they are separate agencies with separate filing addresses.

A misconception is that NIOSH decides claims. NIOSH only computes dose; DEEOIC decides eligibility.

FAQs

Is Form EE-4 the same as Form EE-3?

No. EE-3 is the claimant’s own employment history filed with the initial claim, while EE-4 is a sworn affidavit, usually from a co-worker, used to corroborate employment when records are missing or incomplete.

Does the affiant need to be notarized?

Yes. A notary stamp is preferred, but DEEOIC also accepts an unsworn declaration under 28 U.S.C. §1746 when notarization is impractical, such as for homebound elderly affiants.

Can my spouse sign an EE-4 for me?

No. A spouse can technically sign, but DEEOIC’s Procedure Manual treats family affidavits as biased and almost always requires non-family corroboration before accepting them.

Will one co-worker affidavit be enough?

No. One co-worker affidavit is “some evidence,” but DEEOIC usually requires two unrelated affiants to meet the substantial evidence threshold under 20 CFR §30.111.

Can I submit EE-4 through the ECOMP portal?

Yes. Uploading a signed scan to the ECOMP portal timestamps receipt instantly and avoids 2 to 3 weeks of postal transit and mailroom indexing.

Is there a deadline to file EE-4?

Yes. When DEEOIC issues a 30-day Development Letter, you must respond within that window, although late submissions are still considered before the Recommended Decision is finalized.

Can EE-4 establish Special Exposure Cohort membership?

Yes. A properly detailed EE-4 specifying building, process, and dates can establish SEC class membership, which converts certain cancers into automatic Part B awards.

Does EE-4 help Part E claims?

Yes. Detailed exposure narratives feed the Site Exposure Matrices, which DEEOIC uses to link toxic substances to diagnosed illnesses for Part E causation.

Can my Authorized Representative sign EE-4 for me?

No. The affiant must have personal knowledge of the worker’s employment, and an Authorized Representative without that knowledge cannot serve as the affiant, although they can prepare and submit the form.

What happens if I lie on EE-4?

Yes, there are serious consequences. False statements violate 18 U.S.C. §1001, expose the affiant to criminal prosecution, and trigger automatic claim denial plus referral to the DOL OIG.

Can I amend an EE-4 I already filed?

Yes. You can submit a corrected EE-4 with a cover letter explaining the change, but DEEOIC may treat unexplained amendments as credibility problems, so include documentation supporting the correction.

Is EE-4 used for Beryllium Vendor claims?

Yes. Beryllium Vendor employees use the same EE-4 form, but the affiant must specify the vendor facility (such as Brush Wellman Reading or Hazleton) and the beryllium-handling process observed.

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