Pharmacy - Outpatient Prescription Pharmaceuticals

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⚠️ Notice: This information collection may be referencing outdated material.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
App Y. Outpatient Prescription Pharmaceuticals.docx Other-Dummy Form Representing an Ele
App Y. Outpatient Prescription Pharmaceuticals.docx Other-Dummy Form Representing an Ele

Information Collection (IC) Details

IC Title:	Pharmacy - Outpatient Prescription Pharmaceuticals	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
Other-Dummy Form Representing an Electronic Data Transfer			App Y. Outpatient Prescription Pharmaceuticals.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: 150	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	-39,150	39,150
Annual IC Time Burden (Hours)	-653	653
Annual IC Cost Burden (Dollars)	-9,200	9,200

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.