World Trade Center Health Program Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program

Forms and Documents

Document Name	Status
Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center Form and Instruction	New
Form 1 Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program Form and Instruction	Removed
HSRB 15-OD-NR01 010815 WeissR WTC-related health condition.docx Supplementary Document	2015-04-03
Appendix A.docx Supplementary Document	2015-04-03
Attachment A_Zadroga Act.pdf Supplementary Document	2015-04-03
Att B 60 Day.pdf Supplementary Document	2015-04-03
Supporting Statement B.docx Supporting Statement B	2015-04-03
Supporting Statement A.docx Supporting Statement A	2015-04-03
Attachment D_NIOSH final rule 42 cfr 88.17 for OMB PRA review 1.17.12.docx Supplementary Document	2012-01-27

IC Document Collections

IC ID	Document Title	Status
215958	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center Form and Instruction	New
212076	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program Form and Instruction	Removed

ICR Details

OMB Control No: 0920-0929	ICR Reference No: 201503-0920-016
Status: Historical Active	Previous ICR Reference No: 201406-0920-015
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0929
Title: World Trade Center Health Program Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/09/2015
	Date Received in OIRA: 04/07/2015
Terms of Clearance: Approved consistent with the provisions of the associated final rule (RIN 0920-AA45).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	20	0	100
Time Burden (Hours)	800	0	4,000
Cost Burden (Dollars)	0	0	0

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Abstract: PHS Act §3312(a)(3) identifies a list of health conditions for which individuals who are enrolled in the WTC Health Program may be monitored or treated. PHS Act §3312(a)(6)(B) specifies that interested parties may petition the Administrator of the WTC Health Program to request that a new health condition be added to the List of WTC-Related Health Conditions in 42 C.F.R. §88.1. To aid the petitioner, the WTC Health Program provides a petition form to be completed and then sent to the Administrator for review. However, the petitioner is not required to use the form, and may submit a petition in a different format, provided it contains all of the data elements requested on the form.

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Authorizing Statute(s): PL: Pub.L. 111 - 347 3312 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
  

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:
	80 FR 3239	01/22/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 18238	04/03/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	1	Petition for the Addition of health conditions
Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center	None	Petition for the Addition of a New WTC-related Health Condition for Coverage under the WTC Health Program

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ICR Summary 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	20	100	0	0	-80	0
Annual Time Burden (Hours)	800	4,000	0	0	-3,200	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: ICR Revision 0920-0929 is a revision of the ICR to allow individuals to submit petitions to add conditions to a list of conditions for which enrollees in the WTC Health Program can be monitored.

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Annual Cost to Federal Government: $34,480

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: 04/07/2015

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