88.9 World Trade Center Health Program Survivor Eligibility Application

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⚠️ Notice: This information collection may be referencing outdated material.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
Appendix E Revised Eligibility Form for Survivors 20110624.doc Instruction
Survivors Appendix E (survivors).docx Form and Instruction

Information Collection (IC) Details

IC Title:	88.9 World Trade Center Health Program Survivor Eligibility Application	Agency IC Tracking Number:	14AGX

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
Instruction			Appendix E Revised Eligibility Form for Survivors 20110624.doc		No	No	Printable Only
Form and Instruction	none	Survivors	Appendix E (survivors).docx		No		Paper 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: 1,560	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	1,560	1,560
Annual IC Time Burden (Hours)	390	390
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.