Medical Travel Refund Request

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

Documents and Forms

Document Name Document Type
Medical Travel Refund Request Form
Medical Travel Refund Request Appendix E WTC Health Program Medical Travel Refund Request.docx Form

Information Collection (IC) Details

IC Title:	Medical Travel Refund Request	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
Form	none	Medical Travel Refund Request	Appendix E WTC Health Program Medical Travel Refund Request.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: 78 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)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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