World Trade Center Enrollment & Appeals - Pentagon & Shanksville

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Responder Travel Refund Request	Form	New	Available
Responder Eligibility Application	Form and Instruction	New	Available
Supporting Statement B 11.1.13.docx	Supporting Statement B	Uploaded 2013-11-07	Available
Appendix K.pdf	Supplementary Document	Uploaded 2013-11-07	Available
Appendix J.pdf	Supplementary Document	Uploaded 2013-11-07	Available
Appendix I.docx	Supplementary Document	Uploaded 2013-11-07	Available
60 day FRN.pdf	Supplementary Document	Uploaded 2013-11-07	Available
Appendix A Zadroga Act.docx	Supplementary Document	Uploaded 2013-11-07	Available
Denial Letter F-1 - Treatment.docx	Supplementary Document	Uploaded 2013-11-07	Available
Denial Letter Health Condition E-1.docx	Supplementary Document	Uploaded 2013-11-07	Available
Denial Letter C-1 - Eligibility.docx	Supplementary Document	Uploaded 2013-11-07	Available
World Trade Center Supptg Stmt A PA_VA application 11 7 13.docx	Supporting Statement A	Uploaded 2013-11-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209339	Responder Travel Refund Request	Form	New
209338	Pharmacies Outpatient Prescription Pharmaceuticals	Other-Electronic Claims Submission	New
209337	Responder Appeals Treatment	Other-Letter	New
209336	Responder Appeals Certification of Health Conditions	Other-Letter	New
209335	Responder Appeals to Eligibility Denial	Other-Letter	New
209334	Responder Eligibility Application	Form and Instruction	New

ICR Details

OMB Control No: 0920-1001	ICR Reference No: 201311-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 20876
Title: World Trade Center Enrollment & Appeals - Pentagon & Shanksville
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2013
	Date Received in OIRA: 11/14/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved
Responses	2,685	0	0
Time Burden (Hours)	831	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Title XXXIII of the Public Health Safety Act establishes the World Trade Center (WTC) Health Program within the Department of Health and Human Services. This program provides medical monitoring and treatment benefits to responders to the September 11, 2001 terrorist attacks in New York City, at the Pentagon, and in Shanksville, PA, and to survivors of the terriorist attacks in New York City.

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Authorizing Statute(s): US Code: 33 USC 3311 Name of Law: Zadroga Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA48	Final or interim final rulemaking	78 FR 18855	03/28/2013

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 54471	09/04/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 67148	11/08/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Responder Eligibility Application	none	Eligibility Application
Responder Appeals to Eligibility Denial
Responder Appeals Certification of Health Conditions
Responder Appeals Treatment
Pharmacies Outpatient Prescription Pharmaceuticals
Responder Travel Refund Request	none	Travel Refund Request

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ICR Summary of Burden

table that charts list of burden

	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	2,685	0	0	2,685	0	0
Annual Time Burden (Hours)	831	0	0	831	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new data collection request.

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Annual Cost to Federal Government: $64,425

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 11/14/2013

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