Form 1 Petition for the Addition of a New WTC-Related Health Co

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx

Petition for the Addition of a New WTC-Related Health
Condition for Coverage under the World Trade Center
(WTC) Health Program
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
General Instructions
Any interested party may petition the WTC Program Administrator to add a condition to the list of WTC-related
health conditions in 42 CFR §88.1 (see page 5, below, for the full list).
Please use this form to propose the addition of a health condition (any recognized medical condition requiring
treatment or medication) to the list of WTC-related health conditions. Please use a separate form to propose a
different health condition.
Use of this petition form is voluntary but any petition must include the information requested below, as required
by 42 CFR §88.17. Petitions which fail to provide the required information will not be considered by the WTC
Program Administrator.
Petitions received, including attachments and other supporting materials (which are allowed and encouraged,
but not required), are part of the public record and may be subject to public disclosure. Personal information
will be redacted prior to public disclosure.
Please TYPE or PRINT all information clearly on the form.
If you need more space to provide the required information, please attach additional pages to this form.
Mail or email this form to:

World Trade Center Health Program
395 E. Street, S.W., Suite 9200
Washington, D.C. 20201
[email protected]

Public reporting burden of this collection of information is estimated to average 40 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:
PRA (0920-XXXX).

A. Interested Party Information
A1. Do you represent an organization?  Yes (Go to A2)  No (Go to A3)
A2. Organization Information:
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Name of organization
A3. Name of Individual Petitioner or Organization Representative:
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First name
Last name
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Position, if representative of organization
A4. Mailing Address:
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Street
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City
State
Zip code
A5. Telephone Number: ______________________________________________
A6. Email Address: __________________________________________________

B. Proposed WTC-Related Health Condition Information
B1. Health Condition Information:
_______________________________________________________________________________________
Name of health condition

_______________________________________________________________________________________
If the name of the condition is not known, please provide a description of the condition or the name of the
diagnosis provided by a physician or other healthcare provider.

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C. Basis for Proposing that the Condition Be Added to the List of WTC-Related Health Conditions
C1. Describe the reasons the WTC Program Administrator should consider the addition of this health
condition. Explain how the health condition you are proposing relates to the exposures that may have
occurred from the September 11, 2001, terrorist attacks. Your explanation must include a medical
basis for the relationship/association between the 9/11 exposure and the proposed health condition. If
you need more space, please attach additional pages to this form.
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D. Signature of Petitioner
Sign your name below to indicate that you are petitioning the WTC Program Administrator to consider adding a
health condition to the list of WTC-related health conditions identified in 42 CFR §88.1.

_________________________________________________________________________________________
Signature
Date

Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. §552a), you are hereby notified of the
following:
Title I of the James Zadroga 9/11 Health and Compensation Act of 2010 amended the Public Health Service Act
(PHS Act) to establish the World Trade Center (WTC) Health Program. Sections 3311, 3312, and 3321 of Title
XXXIII of the PHS Act require that the WTC Program Administrator develop regulations to implement
portions of the WTC Health Program established within the Department of Health and Human Services (HHS).
The WTC Health Program is administered by the Director of the National Institute for Occupational Safety and
Health (NIOSH), within the Centers for Disease Control and Prevention (CDC). The information provided with
this form and supporting documentation will be used by the WTC Program Administrator to consider the
disposition of a petitioned-for health condition. Disclosure of this information is voluntary.
Records containing information in identifiable form become part of an existing NIOSH system of records under
the Privacy Act, 0920-0147 “Occupational Health Epidemiological Studies, EEOICPA Program Records and
WTC Health Program Records, HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless
otherwise compelled by law.
NIOSH may disclose information in identifiable form to the WTC Health Program Scientific/Technical
Advisory Committee (STAC), which may be asked to consider the petition and issue a recommendation to the
WTC Program Administrator. Information in identifiable form will be redacted from submitted petition forms
and supporting documentation that become a part of the public record (e.g. in conjunction with STAC
consideration or a rulemaking).

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List of WTC-Related Health Conditions in 42 CFR §88.1
List of WTC-related health conditions means the following disorders and conditions, including any other
condition added to the list through procedures specified by the Act and under this part:
(1) Aerodigestive disorders:
(i) Interstitial lung disease.
(ii) Chronic respiratory disorder [fumes/vapors].
(iii) Asthma.
(iv) Reactive airways dysfunction syndrome [RADS].
(v) WTC-exacerbated chronic obstructive pulmonary disease [COPD].
(vi) Chronic cough syndrome.
(vii) Upper airway hyperactivity.
(viii) Chronic rhinosinusitis.
(ix) Chronic nasopharyngitis.
(x) Chronic laryngitis.
(xi) Gastroesophageal reflux disorder [GERD].
(xii) Sleep apnea exacerbated by or related to a condition described in preceding paragraphs (1)(i)
through (1)(xi)of this definition.
(2) Mental health conditions:
(i) Posttraumatic stress disorder.
(ii) Major depressive disorder.
(iii) Panic disorder.
(iv) Generalized anxiety disorder.
(v) Anxiety disorder [not otherwise specified].
(vi) Depression [not otherwise specified].
(vii) Acute stress disorder.
(viii) Dysthymic disorder.
(ix) Adjustment disorder.
(x) Substance abuse.
(3) Musculoskeletal disorders for those WTC responders who received any treatment for a World Trade
Center (WTC)-related musculoskeletal disorder (as defined in this section) on or before September 11,
2003:
(i) Low back pain.
(ii) Carpal tunnel syndrome [CTS].
(iii) Other musculoskeletal disorders.

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