World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Document Name	Status
Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction	Modified
Form 12 Currently Identified Responders and Currently Identified Survivors Form	Modified
Form 2 88.12 World Trade Center Health Condition Certification Request Form and Instruction	Modified
Form 88.5 88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction	Modified
Justification for WTC Change 12_23_2011.docx Justification for No Material/Nonsubstantive Change	2011-12-22

IC Document Collections

IC ID	Document Title	Status
200509	ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction	Modified
200508	Currently Identified Responders and Currently Identified Survivors Form	Modified
198312	88.16 Travel Expenses	Modified
198311	Outpatient Prescription Pharmaceuticals	Modified
198310	88.15 Denial Letter and Appeal Notification- Health Conditions	Modified
198309	88.15 Denial Letter and Appeal Notification Treatment	Modified
198308	88.12 World Trade Center Health Condition Certification Request Form and Instruction	Modified
198307	88.11 Denial Letter and Appeal Notification Eligibility Instruction	Modified
198306	88.9 World Trade Center Health Program Survivor Eligibility Application Instruction	Modified
198305	88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction	Modified
198304	88.5 World Trade Center Health Program FDNY Responder Eligibility App Instruction	Modified

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 201112-0920-016
Status: Historical Active	Previous ICR Reference No: 201112-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/27/2011
	Date Received in OIRA: 12/27/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	12/31/2014	12/31/2014
Responses	77,243	0	77,243
Time Burden (Hours)	19,161	0	19,161
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA44	Final or interim final rulemaking	76 FR 38913	07/01/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

IC Title	Form No.	Form Name
88.5 World Trade Center Health Program FDNY Responder Eligibility App
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
88.12 World Trade Center Health Condition Certification Request	2	New Determinations for WTC Certification
88.11 Denial Letter and Appeal Notification Eligibility
88.15 Denial Letter and Appeal Notification Treatment
88.15 Denial Letter and Appeal Notification- Health Conditions
Outpatient Prescription Pharmaceuticals
88.16 Travel Expenses
Currently Identified Responders and Currently Identified Survivors	12	Eligibility and Qualification for WTC Health Program
ACH Vendor/Miscellaneous Payment Enrollment Form	11	ACH Vendor/Miscellaneous Payment Enrollment Form

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ICR Summary 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	77,243	77,243	0	0	0	0
Annual Time Burden (Hours)	19,161	19,161	0	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:

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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

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Common Form ICR:  No

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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: 12/27/2011

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