Information Collection

General Responder Eligibility Application

IC 214324 under ICR 202201-0920-002 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
General Responder Eligibility Application	Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App D NYCResponderEligibility.docx	Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App D NYCResponderEligibility.docx	Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App E Responder Spanish.docx	Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App E Responder Spanish.docx	Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App F Responder Polish.docx	Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App F Responder Polish.docx	Form and Instruction

IC Title:

General Responder Eligibility Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [English]	App D NYCResponderEligibility.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [Spanish]	App E Responder Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [Polish]	App F Responder Polish.docx	Yes	Yes	Fillable Fileable

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: 6,215

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	6,215	3,740	2,475
Annual IC Time Burden (Hours)	3,108	1,870	1,238
Annual IC Cost Burden (Dollars)	56,557	34,034	22,523

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.