Authorization Form on behalf of Claimant under 42 CFR 83.7

[NIOSH] EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

OMB: 0920-0639

IC ID: 180186

Information Collection (IC) Details

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Authorization Form on behalf of Claimant under 42 CFR 83.7
 
No Unchanged
 
Voluntary
 
42 CFR 83.7

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Energy Employees for Addition to the Special Exposure Cohort Attachment E Authorization Form 2019_09_20.pdf Yes Yes Fillable Fileable

Income Security Survivor Compensation

09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program   68 FR 55962

3 0
   
Individuals or Households
 
   10 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3 0 0 0 0 3
Annual IC Time Burden (Hours) 0 0 0 0 0 0
Annual IC Cost Burden (Dollars) 1 0 0 0 0 1

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