Information Collection Request
[NIOSH] EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)
ICR 202211-0920-005 · OMB 0920-0639 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-0639 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form A: Special Exposure Cohort Petition 42 CFR 83.9 |
Form and Instruction | Unchanged | Repair queued |
| Authorization Form on behalf of Claimant under 42 CFR 83.7 |
Form and Instruction | Unchanged | Repair queued |
| Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 |
Form and Instruction | Unchanged | Repair queued |
 Attachment F HSRB NR Determination 2022_12_01.pdf |
Supplementary Document | Uploaded 2022-12-06 | Repair queued |
| Attachment B 60-day FRN 2022_08_03.pdf |
Supplementary Document | Uploaded 2022-12-06 | Repair queued |
| Attachment A EEOICPA.pdf |
Supplementary Document | Uploaded 2019-09-23 | Repair queued |
 SSB_0639_102622.docx |
Supporting Statement B | Uploaded 2022-12-06 | Repair queued |
| SSA_0639_rev.120122.docx |
Supporting Statement A | Uploaded 2022-12-06 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 7107 |  Form A: Special Exposure Cohort Petition 42 CFR 83.9 |
Form and Instruction | Unchanged | |
| 180186 | Authorization Form on behalf of Claimant under 42 CFR 83.7 |
Form and Instruction | Unchanged | |
| 180185 | Petitioner Appealing Final Decision under 42 CFR 83.18 |
Other-Example Request for Review | Unchanged | |
| 180184 | Petitioner Submission Format other than Form B 42 CFR 83.9 |
Instruction | Unchanged | |
| 180183 | Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 |
Form and Instruction | Unchanged |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CDC |
| OMB Control No | 0920-0639 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 201909-0920-003 |
| Agency Tracking No | 0920-0639 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |