Information Collection

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

IC 212076 under ICR 201503-0920-016 · OMB 0920-0929.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
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
1 Petition for the Addition of health conditions Attachment C (clean).docx	Form and Instruction
Attachment C (revised).docx Attachment C (revised)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Petition for the Addition of health conditions	Attachment C (clean).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-100	100
Annual IC Time Burden (Hours)	-4,000	4,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C (revised)	Attachment C (revised).docx	06/25/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.