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

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

Documents and Forms

Document Name Document Type
Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center Form and Instruction
Petition for the Addition of a New WTC-related Health Co ATT C WTCHP petition form REVISED.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Petition for the Addition of a New WTC-related Health Condition for Coverage under the WTC Health Program	ATT C WTCHP petition form REVISED.docx	None	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH	FR Citation: 76 FR 34706

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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