Information Collection

Survivor Eligibility Application

IC 214326 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⚠️ Notice: This information collection may be referencing outdated material.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
Survivor Eligibility Application	Form and Instruction
Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx	Form and Instruction
Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx	Form and Instruction
Eligibility Application for Survivors [Spanish] App I Survivors Spanish.docx	Form and Instruction
Eligibility Application for Survivors [Spanish] App I Survivors Spanish.docx	Form and Instruction
Eligibility Application for Survivors [Polish] App J Survivors Polish.docx	Form and Instruction
Eligibility Application for Survivors [Polish] App J Survivors Polish.docx	Form and Instruction
Eligibility Application for Survivors [Chinese] App K Survivors Chinese.docx	Form and Instruction
Eligibility Application for Survivors [Chinese] App K Survivors Chinese.docx	Form and Instruction

IC Title:

Survivor 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?	Electronic Capability
Form and Instruction	n/a	Eligibility Application for Survivors [English]	App H Eligibility_Form_for_Survivors.docx	No	Paper Only
Form and Instruction	n/a	Eligibility Application for Survivors [Spanish]	App I Survivors Spanish.docx	No	Paper Only
Form and Instruction	n/a	Eligibility Application for Survivors [Polish]	App J Survivors Polish.docx	No	Paper Only
Form and Instruction	n/a	Eligibility Application for Survivors [Chinese]	App K Survivors Chinese.docx	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: 9,240

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	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,240	7,890	1,350
Annual IC Time Burden (Hours)	4,620	3,945	675
Annual IC Cost Burden (Dollars)	55,440	47,340	8,100

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.