World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 88.16 Travel Expenses	Form and Instruction	New	Available
Form 88.5 88.5 World Trade Center Health Program Responder App (Other than FDNY)	Form and Instruction	New	Available
Form 88.3 88.3, 88.7 Eligibility and Qualification for WTC Health Program	Form and Instruction	New	Available
Appendis B Eligibility and Qualification 20110623.doc	Supplementary Document	Uploaded 2011-06-24	Available
World Trade Center Supptg Stmt A 6 24 11.doc	Supporting Statement A	Uploaded 2011-06-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198312	88.16 Travel Expenses	Form and Instruction	New
198311	Outpatient Prescription Pharmaceuticals		New
198310	88.15 Denial Letter and Appeal Notification- Health Conditions		New
198309	88.15 Denial Letter and Appeal Notification Treatment		New
198308	88.12 World Trade Center Health Condition Certification Request		New
198307	88.11 Denial Letter and Appeal Notification Eligibility	Instruction	New
198306	88.9 World Trade Center Health Program Survivor Eligibility Application	Instruction	New
198305	88.5 World Trade Center Health Program Responder App (Other than FDNY)	Form and Instruction	New
198304	88.5 World Trade Center Health Program FDNY Responder Eligibility App	Instruction	New
198303	88.3, 88.7 Eligibility and Qualification for WTC Health Program	Form and Instruction	New

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 201112-0920-007
Status: Historical Active	Previous ICR Reference No: 201106-0920-016
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2011
	Date Received in OIRA: 12/13/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	6 Months From Approved
Responses	77,043	0	0
Time Burden (Hours)	19,111	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The proposed collection will collect enrollment and appeals data as required by the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Zadroga Act which was passed on December 22, 2010 establishes a federal program to support health monitoring and treatment for emergency responders; recovery and cleanup workers; and residents, building occupants, and area workers in New York City who were directly impacted and adversely affected by the terrorist attacks of September 11, 2001. All responders to the New York City attack who will be newly seeking medical monitoring and treatment and survivors of the attack who were not covered by the Medical Monitoring and Treatment Program (MMTP) prior to January 2, 2011, may apply to obtain coverage under the new WTC Health Program. In order to begin the determination eligibility process, an enrollment form must be completed. There are three separate enrollment forms for each population of responders (FDNY responders, non-FDNY responders, and Survivors). The enrollment form will collect general contact information as well as information regarding the WTC disaster area experience. In order to reduce the burden on the respondents and survivors, the WTC Health program will make the form available to be downloaded from the internet or obtained in hard copy and submitted by mail.

---

Authorizing Statute(s): PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  

Citations for New Statutory Requirements: PL: Pub.L. 847 - 42 88 Name of Law: CFR

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA44	Final or interim final rulemaking	76 FR 127	07/01/2011

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
88.5 World Trade Center Health Program FDNY Responder Eligibility App
88.3, 88.7 Eligibility and Qualification for WTC Health Program	88.3	Eligibility Currently identified Responders
Outpatient Prescription Pharmaceuticals
88.16 Travel Expenses	1	Travel Refund Request
88.5 World Trade Center Health Program Responder App (Other than FDNY)	88.5	World Trade Center Health Program Responder App (Other than FDNY)
88.9 World Trade Center Health Program Survivor Eligibility Application
88.11 Denial Letter and Appeal Notification Eligibility
88.12 World Trade Center Health Condition Certification Request
88.15 Denial Letter and Appeal Notification Treatment
88.15 Denial Letter and Appeal Notification- Health Conditions

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	77,043	0	77,043	0	0	0
Annual Time Burden (Hours)	19,111	0	19,111	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR emergency submission provided under Public Law 847-42 -88 Zadroga Act

---

Annual Cost to Federal Government: $95,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/27/2011

---