Information Collection

Responder Appeals Certification of Health Conditions

IC 209336 under ICR 201311-0920-009 · OMB 0920-1001.

Documents and Forms

Document Name Document Type
Appendix E Appeal Letter Health Condition.docx Other-Letter
Denial Letter Health Condition E-1.docx Denial Letter - Health Condition IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Responder Appeals Certification of Health Conditions	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
Other-Letter			Appendix E Appeal Letter Health Condition.docx		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, EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH	FR Citation: 76 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 Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Denial Letter - Health Condition	Denial Letter Health Condition E-1.docx	11/07/2013

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