Information Collection

88.12 World Trade Center Health Condition Certification Request

IC 198308 under ICR 201406-0920-001 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

88.12 World Trade Center Health Condition Certification Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 88.12

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.