Form 12 Eligibility and Qualification for WTC Health Program

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

[Insert Address]

Dear [insert Name]

You have been identified as someone who may be eligible to be enrolled in the World Trade Center (WTC) Health Program. In order to verify that you are eligible and qualified for the program, we need you to provide the information specified in the attached form. You are not required to provide this information but we may not be able to enroll you if you do not. Please return this information in the envelope provided.

Sincerely,

WTC Program Administrator

ELIGIBILITY AND QUALIFICATION FOR WTC HEALTH PROGRAM

1. Full Name

________________________________________________________________________

(last, first, and middle names)

2. Complete Address

________________________________________________________________________

(street name and number, city, state, and zip code)

3. Phone Number(s)

_________________________________________________

(home)

___________________________________________________

(cell)

4. Date of Birth

_______________________________________________________

5. Gender: Circle one: M F

6. Last 4 digits of your Social Security Number:_________________

7. Place of Birth

_________________________________________________________

(birth city and state or country)

8. Government ID number (e.g., driver’s license number, passport)

__________________________________________________________

(number, type of ID)

Public reporting burden of this collection of information is estimated to average 10 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).

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.