Information Collection

Appeals regarding Certification of Health Conditions

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Appeals regarding Certification of Health Conditions	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Document			Appendix F Appeal Letter Health Condition .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: 1	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	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Denial Letter Sample	Denial Letter Health Condition F-1.docx	03/31/2013

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