88.5 World Trade Center Health Program Responder App (Other than FDNY)

World Trade Center Health Program Enrollment, Appeals & Reimbursement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Document Name Document Type
Form 88.5 88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction
88.5 World Trade Center Health Program Responder App (Other t Appendix D Revised Eligibility Form for Responders Non FDNY 20110623.doc Form and Instruction

Information Collection (IC) Details

IC Title:	88.5 World Trade Center Health Program Responder App (Other than FDNY)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	88.5	World Trade Center Health Program Responder App (Other than FDNY)	Appendix D Revised Eligibility Form for Responders Non FDNY 20110623.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and CCOICPA Program Records, and WTC Program Records HHS/CDC/NIOSH	FR Citation: 76 FR 31212

Number of Respondents: 2,979	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,979	2,979
Annual IC Time Burden (Hours)	1,490	1,490
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.