Appeals regarding Eligibility Denial

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

Documents and Forms

Document Name Document Type
Appendix C Appeal to Eligibility Denial.docx Other-Document
Denial Letter C-1 - Eligibility.docx Denial Letter Sample IC Document

Information Collection (IC) Details

IC Title:	Appeals regarding Eligibility Denial	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Document			Appendix C Appeal to Eligibility Denial.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Occupational Health epidemiological Studies and EEOICPA Program Records and WTC Probram Records	FR Citation: 76 FR 31212

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Denial Letter Sample	Denial Letter C-1 - Eligibility.docx	03/31/2013

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