Responder Medical Travel Refund Request

World Trade Center Health Program Enrollment, Appeals & Reimbursement

OMB: 0920-0891

IC ID: 214337

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Responder Medical Travel Refund Request
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a Medical Travel Refund Request App CC Travel Refund Request.docx No   Paper Only

Health Health Care Services

09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH  76 FR 34706

10 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 10 0 0 0 0 10
Annual IC Time Burden (Hours) 2 0 0 0 0 2
Annual IC Cost Burden (Dollars) 25 0 25 0 0 0

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.

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