World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 201307-0920-001

OMB: 0920-0891

Federal Form Document

ICR Details
0920-0891 201307-0920-001
Historical Active 201112-0920-016
HHS/CDC 19888
World Trade Center Health Program Enrollment, Appeals & Reimbursement
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 07/03/2013
Retrieve Notice of Action (NOA) 07/01/2013
  Inventory as of this Action Requested Previously Approved
12/31/2014 12/31/2014 12/31/2014
77,243 0 77,243
19,161 0 19,161
0 0 0

This is a request to extend data collection beyond the current expiration date. The collection will continue to collect enrollment and appeals data as required by the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Zadroga Act which was passed on December 22, 2010 establishes a federal program to support health monitoring and treatment for emergency responders; recovery and cleanup workers; and residents, building occupants, and area workers in New York City who were directly impacted and adversely affected by the terrorist attacks of September 11, 2001. All responders to the New York City attack who will be newly seeking medical monitoring and treatment and survivors of the attack who were not covered by the Medical Monitoring and Treatment Program (MMTP) prior to January 2, 2011, may apply to obtain coverage under the new WTC Health Program. In order to begin the determination eligibility process, an enrollment form must be completed. There are three separate enrollment forms for each population of responders (FDNY responders, non-FDNY responders, and Survivors). The enrollment form will collect general contact information as well as information regarding the WTC disaster area experience. In order to reduce the burden on the respondents and survivors, the WTC Health program will make the form available to be downloaded from the internet or obtained in hard copy and submitted by mail.

PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  
None

0920-AA44 Final or interim final rulemaking 76 FR 38913 07/01/2011

No

  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 77,243 77,243 0 0 0 0
Annual Time Burden (Hours) 19,161 19,161 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$95,500
No
Yes
No
No
No
Uncollected
Petunia Gissendaner 4046390164

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/01/2013


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