Information Collection

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

IC 215958 under ICR 201503-0920-016 · OMB 0920-0929.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.