General Responder Eligibility Application

[NIOSH] 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⚠️ Notice: This information collection may be referencing outdated material.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
General Responder Eligibility Application Form and Instruction
General Responder Eligibility Application Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App D NYCResponderEligibility.docx Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App D NYCResponderEligibility.docx Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App E Responder Spanish.docx Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App E Responder Spanish.docx Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App F Responder Polish.docx Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App F Responder Polish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	General Responder Eligibility Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [English]	App D NYCResponderEligibility.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [Spanish]	App E Responder Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [Polish]	App F Responder Polish.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: 6,215	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,215	6,215
Annual IC Time Burden (Hours)	3,108	3,108
Annual IC Cost Burden (Dollars)	56,557	56,557

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.