World Trade Center Health Program Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	Form and Instruction	New	Available
Form 1 Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	Form and Instruction	Removed	Available
Mini-supporting statement (change request).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-06-25	Available
Attachment A_Zadroga Act.pdf	Supplementary Document	Uploaded 2012-01-27	Available
Attachment D_NIOSH final rule 42 cfr 88.17 for OMB PRA review 1.17.12.docx	Supplementary Document	Uploaded 2012-01-27	Repair queued
SuppStatemen World Trade Center Health Program New Condition Petitions 1.17.12.docx	Supporting Statement A	Uploaded 2012-01-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212076	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	Form and Instruction	New
200945	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	Form and Instruction	Removed

ICR Details

OMB Control No: 0920-0929	ICR Reference No: 201406-0920-015
Status: Historical Active	Previous ICR Reference No: 201201-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-092914AGW
Title: World Trade Center Health Program Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/07/2014
	Date Received in OIRA: 06/26/2014
Terms of Clearance: Previous terms of clearance apply.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	04/30/2015	04/30/2015
Responses	100	0	100
Time Burden (Hours)	4,000	0	4,000
Cost Burden (Dollars)	0	0	0

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Abstract: This submission is to account for non-substantive changes to 0920-0929 (World Trade Center Health Program Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center Health Program, expiration 4/30/2015). The James Zadroga 9/11 Health and Compensation Act of 2010 (the Act) established the World Trade Center (WTC) Health Program. The law requires the WTC Health Program to provide monitoring and treatment benefits to responders and survivors who are determined to be eligible for the Program. The Act included a list of WTC-related health conditions (42 CFR § 88.1) which are covered for treatment by the Program. The Act also allows any interested party to petition the WTC Program Administrator to add a condition to the list. The Program has created a form that has been approved by OMB (0920-0929) to help an individual(s) provide the necessary information to request the Program Administrator to add a condition.

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Authorizing Statute(s): PL: Pub.L. 111 - 347 3312 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA45	Final or interim final rulemaking	76 FR 38938	07/01/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	1	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program
Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	1	Petition for the Addition of health conditions

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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	100	100	0	0	0	0
Annual Time Burden (Hours)	4,000	4,000	0	0	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: The revised form improves clarity for the petitioner and to accurately reflect the current list of covered conditions. The following changes will be made: In the first sentence of the General Instructions section, the current petition refers people to page 5 for a full list of covered conditions. Since that list has changed over time we are going to remove that sentence and page 5 of the listed conditions and refer people to the website for the full and current list of covered conditions. This will prevent any future changes to the petition form as the current list is always updated on the website. The language was modified in section C1 to make it clearer what information needs to be provided by the petitioner in support of the petition. Minor grammatical changes have been made to throughout the form for clarity. No additional burden will be added to the respondents as this collection is already accounted for in the current OMB package (0920-0929). The respondent does not complete any additional paperwork as the edits are minor changes to current language on the applications.

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Annual Cost to Federal Government: $34,480

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

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: 06/26/2014

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