88.9 World Trade Center Health Program Survivor Eligibility Application

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

World Trade Center Health Program

Survivor Eligibility Application

A World Trade Center (WTC) Health Program Survivor is a person who was present in the disaster area in the aftermath of the September 11, 2001, terrorist attacks on the World Trade Center as a result of their work, residence, or attendance at school, childcare, or adult daycare.

If you believe that you are eligible to participate in the WTC Health Program, please provide the following information to begin the eligibility determination process:

Today’s Date __ __/__ __/__ __ __ __

Last Name ____________________________________________________

First Name _______________________ Middle Name ______________________

Mailing Address _______________________________________________________

E-mail address __________________________________________

City ________________________ State ___________ Zip Code _______________

Primary Phone # (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___

Secondary Phone # (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___

Date of Birth ___ ___/ ___ ___/ ___ ___ ___ ___ Gender  Male  Female

Place of Birth ___________________________________

Government Identification Number (choose one)

Provision of your Government Identification Number is optional and you may not be denied enrollment in the program for failure to provide it. However your failure to provide it may delay or prevent action on your application.

Public reporting burden of this collection of information is estimated to average 15 minutes 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).

__________________

Driver's License

__________________

Last 4 digits of Social Security Number __________________

Passport

__________________

Other (what type?)

Please answer the following questions about your World Trade Center Disaster Area Experience. If you want help in filling out this application or have questions, you may call toll-free 1-###-###-####.

Check any boxes that apply to you.

Note: The "New York City disaster area" is defined as the area in Manhattan that is south of Houston Street and any block in Brooklyn that is wholly or partially contained within a 1.5-mile radius of the former World Trade Center site.

 I was present in the New York City disaster area in the dust or dust cloud on September 11, 2001.

 I worked, lived, or attended school, childcare, or adult daycare in the New York City disaster area. Please fill in the information for the bullets below:

• How many days during the period beginning on September 11, 2001,
  and ending on January 10, 2002? _____

• How many days during the period beginning on January 11, 2002,
  and ending on July 31, 2002? _____

• At what location/address? __________________________________________

 I worked as a cleanup worker or performed maintenance work in the New York City disaster area during the period beginning on September 11, 2001, and ending on January 10, 2002, and I had extensive exposure to WTC dust as a result of such work.

• At what location/address? __________________________________________

 I participated in the Lower Manhattan Development Corporation Residential Grant Program which provided grant money to individuals who owned or purchased and lived in a residence in the New York City disaster area during the time period of September 11, 2001, and May 31, 2003.

 I worked for a company in the New York City disaster area that was eligible to receive a grant from the Lower Manhattan Development Corporation WTC Small Firms Attraction and Retention Act program, or other government incentive programs which were created after the September 11, 2001, terrorist attacks to help revitalize the lower Manhattan economy.

 I have symptoms of a physical or emotional health condition that I believe resulted from the September 11, 2001, terrorist attacks. Please briefly describe your symptoms and when they started.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

 None of the above, but I believe that I qualify for the following reason:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Required Documentation

WTC Health Program applicants must also submit documentation providing evidence of location, presence or residence, and/or work activity during the relevant time period specified in the questions above. Documentation may include but is not limited to: proof of residence, such as a lease or utility bill; attendance roster at a school or daycare; or pay stub, other employment documentation, or written statement, under penalty of perjury, by an employer indicating employment location during the relevant time period, or similar documentation.

If you are unable to submit the required documentation, you must explain how you attempted to obtain this documentation and the reason you are unable to provide it with your application.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

I hereby apply to the WTC Health Program and give permission for my personal information to be used by appropriate Federal Government agencies and Federal Government contractors to determine if I am eligible for the WTC Health Program, and to determine whether payments of funds under the WTC Health Program are or were appropriately made in the correct amounts.

By my signature I attest that I have answered the questions truthfully and that I understand the following: Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to gain enrollment in the WTC Health Program to which that person is not entitled is subject to civil and/or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.

_______________________________________ ___________
SIGNATURE DATE

This form may faxed to 1 - (###) ###-#### or mailed to:

World Trade Center Health Program

Address 1

Address 2

Privacy Act Statement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that the WTC Health Program is administered by the Department of Health and Human Services (HHS), which receives and maintains personal information on applicants under 42 U.S.C. §§300mm-300-61. The information received will be used to determine eligibility and qualification for the WTC Health Program and for any subsequent initial health evaluations, monitoring and treatment or other benefit under WTC Health Program.

The information provided may be disclosed to: (1) the Department of Justice and its contractors to provide terrorist screening support in accordance with NIOSH's statutory obligation to determine whether an individual is on the "terrorist watch list" as specified in Section 3311 and Section 3321 of the Zadroga Act and is eligible and qualified to be enrolled or certified in the WTC Health Program as specified by statute; (2) agency contractors who have been contracted by the agency to assist in fulfillment of the agency’s functions relating to the WTC Health Program and who need access to the records in order to carry out the terms of their contracts; (3) applicable entities for the purpose of reducing or recouping WTC Health Program payments made to individuals under a workers’ compensation law or plan of the United States, a State, or locality, or other work-related injury or illness benefit plan of the employer of such worker or public or private health plan as required under Title XXXIII of the Public Health Service Act; and (4) the Department of Justice in litigation involving Title XXXIII.

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