Information Collection

World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey

IC 207187 under ICR 201211-0920-003 · OMB 0920-0953.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
WTCHP- Telephone Script.docx	Instruction
World Trade Center Health Program Member Questionnaire WTCHP Questionnaire.docx	Form and Instruction
WTCHP fast track form.doc WTCHP fast track form	IC Document

IC Title:

World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			WTCHP- Telephone Script.docx		Yes	No	Paper Only
Form and Instruction	None	World Trade Center Health Program Member Questionnaire	WTCHP Questionnaire.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,319

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1,319	0	0	0	0	0
Annual IC Time Burden (Hours)	165	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
WTCHP fast track form	WTCHP fast track form.doc	06/05/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.