Request for Certification of Health Condition (WTC-3)

World Trade Center Health Program Enrollment, Appeals & Reimbursement

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Request for Certification of Health Condition (WTC-3) Form and Instruction
Request for Certification of a WTC Related Health Condit App S WTC-3 Request for Certification.docx Form and Instruction
Request for Certification of a WTC Related Health Condit App S WTC-3 Request for Certification.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Request for Certification of Health Condition (WTC-3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	Request for Certification of a WTC Related Health Condition	App S WTC-3 Request for Certification.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: 20,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-20,000	20,000
Annual IC Time Burden (Hours)	-10,000	10,000
Annual IC Cost Burden (Dollars)	-1,000,000	1,000,000

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.