88.12 World Trade Center Health Condition Certification Request

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⚠️ Notice: This information collection may be referencing outdated material.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 2 88.12 World Trade Center Health Condition Certification Request Form and Instruction
2 New Determinations for WTC Certification Attachment J.docx Form and Instruction

Information Collection (IC) Details

IC Title:	88.12 World Trade Center Health Condition Certification Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 88.12

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	New Determinations for WTC Certification	Attachment J.docx		Yes	No	Fillable Printable

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: 2,300	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	32,200	32,200
Annual IC Time Burden (Hours)	16,100	16,100
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.