This is a request to extend data collection beyond the current expiration date. The collection will continue to 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.
This is a request to extend data collection beyond the current expiration date of 12/31/2011.
$95,500
No
Yes
No
No
No
Uncollected
Petunia Gissendaner 4046390164
Reginfo record details
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:
(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;
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.
Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form
Justification for Extension of 0920 08910920-0891 - World Trade Center Health Program Enrollment, Appeals & Reimbursement.docx
Appendis B Eligibility and Qualification 20110623.doc
ACH Vendor/Miscellaneous Payment Enrollment Form