World Trade Center Health Program Enrollment & Appeals - Pentagon & Shanksville, PA Responders

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Medical Travel Refund Request	Form	New	Available
Form SF 3881 SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form	Form	New	Available
WTC Pentagon & Shanksville, PA Eligibility Application	Form	New	Available
Appendix A Zadroga Act.docx	Supplementary Document	Uploaded 2013-03-31	Available
Denial Letter Health Condition F-1.docx	Supplementary Document	Uploaded 2013-03-31	Available
Denial Letter G-1 - Treatment.docx	Supplementary Document	Uploaded 2013-03-31	Available
Denial Letter C-1 - Eligibility.docx	Supplementary Document	Uploaded 2013-03-31	Available
World Trade Center Supptg Stmt A PA_VA application 3.29.13.docx	Supporting Statement A	Uploaded 2013-03-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206325	Medical Travel Refund Request	Form	New
206324	Outpatient Pharmacies	Other-Document	New
206323	SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form	Form	New
206322	Appeals regarding Certification of Health Conditions	Other-Document	New
206321	Appeals Regarding Treatment	Other-Document	New
206320	Appeals regarding Eligibility Denial	Other-Document	New
206319	WTC Pentagon & Shanksville, PA Eligibility Application	Form	New

ICR Details

OMB Control No: 0920-0962	ICR Reference No: 201304-0920-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 19218
Title: World Trade Center Health Program Enrollment & Appeals - Pentagon & Shanksville, PA Responders
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/01/2013
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/10/2013
	Date Received in OIRA: 04/01/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	6 Months From Approved
Responses	2,690	0	0
Time Burden (Hours)	832	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention seeks approval to expand data collection under the World Trade Center Health Program to include responders and volunteers at the Pentagon and in Shanksville, Pennsylvania.

Emergency Justfication: This emergency clearance is essential for Pentaton and Shanksville, PA responders who wish to apply to the World Trade Center (WTC)Program or appeal a decision by the WTC program. Eligibility criteria are being promulgated by Interim Final Rule which will be effective on May 1, 2013.

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Authorizing Statute(s): US Code: 42 USC 88 Name of Law: James Zadroga Act
  

Citations for New Statutory Requirements: US Code: 42 USC 88 Name of Law: James Zadroga Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA48	Final or interim final rulemaking	78 FR 18855	03/28/2013

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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: 7

table that charts list of burden

IC Title	Form No.	Form Name
WTC Pentagon & Shanksville, PA Eligibility Application	none	Eligibility application
Appeals regarding Eligibility Denial
Appeals Regarding Treatment
Appeals regarding Certification of Health Conditions
SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form	SF 3881	ACH Form
Outpatient Pharmacies
Medical Travel Refund Request	none	Medical Travel Refund Request

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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	2,690	0	2,690	0	0	0
Annual Time Burden (Hours)	832	0	832	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 request for an Emergency Clearance.

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Annual Cost to Federal Government: $64,425

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? No

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: 04/01/2013

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