Information Collection

Appeals regarding Certification of Health Conditions

IC 206322 under ICR 201304-0920-001 · OMB 0920-0962.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix F Appeal Letter Health Condition .docx	Other-Document
Denial Letter Health Condition F-1.docx Denial Letter Sample	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Other-Document					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: 1

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
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Denial Letter Sample		03/31/2013

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

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