Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx
Dear Applicant:
Your application for enrollment in the World Trade Center Health Program has been reviewed, and a determination was made that you are not eligible based on the information that you provided. Specifically, [PROVIDE THE REASON FOR THE DENIAL].
If you would like to appeal this decision, you must submit an explanation of how you believe the information that you provided in your original application was misinterpreted. Please mail your appeal to:
World Trade Center Health Program
Address 1
Address 2
Sincerely,
WTC Program Administrator
Public reporting burden of
this collection of information is estimated to average 30minutes 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).
| File Type | application/msword |
| Author | rmf2 |
| Last Modified By | ziy6 |
| File Modified | 2011-06-24 |
| File Created | 2011-06-24 |