World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Pharmacy	Form	New	Available
Designate a Representative	Form	New	Available
Physician Request for Certification	Form	New	Available
Clinic Selection Postcard	Form	New	Available
Travel Refund Request	Form	New	Available
Denial Letters and Appeal Notification	Form	New	Available
Denial and Appeal Letters	Form	New	Available
Denial Letter and Appeal Notification	Form	New	Available
Survivor Eligibility	Form	New	Available
Pentagon/Shanksville	Form	New	Available
Non FDNY Application	Form	New	Available
FDNY	Form	New	Repair queued
Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form	Form and Instruction	Removed	Available
Form 12 Eligibility and Qualification for WTC Health Program	Form	Removed	Available
Form 2 New Determinations for WTC Certification	Form and Instruction	Removed	Available
Survivors	Form and Instruction	Removed	Available
Eligibility Other than FDNY	Form and Instruction	Removed	Available
Form 88.5 World Trade Center Health Program Responder App (Other than FDNY)	Form and Instruction	Removed	Available
FDNY Responder Eligibility	Form	Removed	Available
Appendix P WTC_6_Final.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix O WTC_5_Final.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix T Pharmacy Prior Authorization_Final.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix S PA3 Transplant_Final.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix R PA3_Dental_Final.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix Q PA3 Standard_Final.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix Z HSRB.pdf	Supplementary Document	Uploaded 2015-09-04	Available
Appendix W Treatment Denial Letter and Appeal Notification.docx	Supplementary Document	Uploaded 2015-09-04	Available
Appendix V Enrollment Denial Letter and Appeal Notification.docx	Supplementary Document	Uploaded 2015-09-04	Available
Appendix U Enrollment Denial Letter and Appeal Notification.docx	Supplementary Document	Uploaded 2015-09-04	Available
Appendix Y Response to Public Comments.docx	Supplementary Document	Uploaded 2015-09-04	Available
Appendix J Public comments.docx	Supplementary Document	Uploaded 2014-12-30	Available
Appendix K IRB.pdf	Supplementary Document	Uploaded 2014-12-18	Available
Appendix B 60dy FRN.pdf	Supplementary Document	Uploaded 2014-12-18	Available
Appendix A Legislation.docx	Supplementary Document	Uploaded 2014-12-18	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2015-09-03	Available
Supptg Stmt A.doc	Supporting Statement A	Uploaded 2015-09-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218099	Pharmacy - Outpatient Prescription Pharmaceuticals	Form	New	Pharmacy
218098	Designated Rep Form	Form	New	Designate a Representative
218097	WTC-3	Form	New	Physician Request for Certification
218096	Clinic Selection Postcard	Form	New	Clinic Selection Postcard
214337	Responder Medical Travel Refund Request	Form	New	Travel Refund Request
214336	Responder Denial and Appeal - Treatment	Form	New	Denial Letters and Appeal Notification
214335	Responder Denial and Appeal - Health Conditions	Form	New	Denial and Appeal Letters
214327	Responder Denial and Appeal - Eligibility	Form	New	Denial Letter and Appeal Notification
214326	Survivor Eligibility	Form	New	Survivor Eligibility
214325	Pentagon / Shanksville Responder	Form	New	Pentagon/Shanksville
214324	General Responder Eligibility Application	Form	New	Non FDNY Application
214323	FDNY Responder Eligibility Application	Form	New	FDNY
200509	ACH Vendor/Miscellaneous Payment Enrollment Form	Form and Instruction	Removed	ACH Vendor/Miscellaneous Payment Enrollment Form
200508	Currently Identified Responders and Currently Identified Survivors	Form	Removed	Eligibility and Qualification for WTC Health Program
198312	88.16 Travel Expenses		Removed
198311	Outpatient Prescription Pharmaceuticals		Removed
198310	88.15 Denial Letter and Appeal Notification- Health Conditions		Removed
198309	88.15 Denial Letter and Appeal Notification Treatment		Removed
198308	88.12 World Trade Center Health Condition Certification Request	Form and Instruction	Removed	New Determinations for WTC Certification
198307	88.11 Denial Letter and Appeal Notification Eligibility	Instruction	Removed
198306	88.9 World Trade Center Health Program Survivor Eligibility Application	Form and Instruction	Removed	Survivors
198306	88.9 World Trade Center Health Program Survivor Eligibility Application	Instruction	Removed
198305	88.5 World Trade Center Health Program Responder App (Other than FDNY)	Form and Instruction	Removed	Eligibility Other than FDNY
198305	88.5 World Trade Center Health Program Responder App (Other than FDNY)	Form and Instruction	Removed	World Trade Center Health Program Responder App (Other than FDNY)
198304	88.5 World Trade Center Health Program FDNY Responder Eligibility App	Form	Removed	FDNY Responder Eligibility
198304	88.5 World Trade Center Health Program FDNY Responder Eligibility App	Instruction	Removed

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 201412-0920-012
Status: Historical Active	Previous ICR Reference No: 201406-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 19888
Title: World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/14/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/30/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved	09/30/2015
Responses	66,276	0	77,243
Time Burden (Hours)	13,594	0	19,161
Cost Burden (Dollars)	0	0	0

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Abstract: The WTC Health Program is a limited healthcare program established by the James Zadroga 9/11 Health and Compensation Act of 2010. The goal of the Program is to provide monitoring and treatment to responders of the 9/11 terrorist attacks at the World Trade Center, Pentagon, and Shanksville, PA, as well as survivors in the New York City Area. The data collected contained within this OMB package are intended solely for determining eligibility and treatment.

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Authorizing Statute(s): PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 39399	07/10/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 77007	12/23/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
88.11 Denial Letter and Appeal Notification Eligibility
88.12 World Trade Center Health Condition Certification Request	2	New Determinations for WTC Certification
88.15 Denial Letter and Appeal Notification Treatment
88.15 Denial Letter and Appeal Notification- Health Conditions
88.16 Travel Expenses
88.5 World Trade Center Health Program FDNY Responder Eligibility App	none	FDNY Responder Eligibility
88.5 World Trade Center Health Program Responder App (Other than FDNY)	88.5, none	World Trade Center Health Program Responder App (Other than FDNY) ,   Eligibility Other than FDNY
88.9 World Trade Center Health Program Survivor Eligibility Application	none	Survivors
ACH Vendor/Miscellaneous Payment Enrollment Form	11	ACH Vendor/Miscellaneous Payment Enrollment Form
Clinic Selection Postcard	none	Clinic Selection Postcard
Currently Identified Responders and Currently Identified Survivors	12	Eligibility and Qualification for WTC Health Program
Designated Rep Form	none	Designate a Representative
FDNY Responder Eligibility Application	none	FDNY
General Responder Eligibility Application	none	Non FDNY Application
Outpatient Prescription Pharmaceuticals
Pentagon / Shanksville Responder	none	Pentagon/Shanksville
Pharmacy - Outpatient Prescription Pharmaceuticals	none	Pharmacy
Responder Denial and Appeal - Eligibility	None	Denial Letter and Appeal Notification
Responder Denial and Appeal - Health Conditions	none	Denial and Appeal Letters
Responder Denial and Appeal - Treatment	none	Denial Letters and Appeal Notification
Responder Medical Travel Refund Request	none	Travel Refund Request
Survivor Eligibility	none	Survivor Eligibility
WTC-3	none	Physician Request for Certification

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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	66,276	77,243	0	-10,967	0	0
Annual Time Burden (Hours)	13,594	19,161	0	-5,567	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: Miscellaneous Actions

Short Statement: This revision request incorporates changes to forms, and the consolidation of two ICRs. There is a reduction in burden hours and respondents.

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Annual Cost to Federal Government: $1,080,300

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: 12/30/2014

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