[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0891 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment	Form and Instruction	New	Repair queued
Form 0920-0891 Designated Representative Revocation Form	Form and Instruction	Unchanged	Repair queued
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties	Form and Instruction	Unchanged	Repair queued
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals	Form and Instruction	Unchanged	Repair queued
Form 0920-0891 Member Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Petition for the Addition of a Health Condition (previously approved under 0920-0929)	Form and Instruction	Unchanged	Repair queued
HIPAA Authorization to Release Information	Form and Instruction	Unchanged	Repair queued
Designated Representative	Form and Instruction	Unchanged	Repair queued
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	Form	Unchanged	Repair queued
Survivor Eligibility Application	Form and Instruction	Unchanged	Repair queued
Pentagon / Shanksville Responder	Form and Instruction	Unchanged	Repair queued
General Responder Eligibility Application	Form and Instruction	Unchanged	Repair queued
FDNY Responder Eligibility Application	Form and Instruction	Unchanged	Repair queued
0920-0891_EmergencyReviewRequest_memo.docx	Supplementary Document	Uploaded 2024-08-22	Repair queued
Request for Nonsubstantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-12	Repair queued
App Y 180 Day Letter Reminder for Additional Information.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App X Survivor 90 Day Suspend Letter.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App W 60 Day Suspend Letter.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App V 30 Day Suspend Letter.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App U Initial Request for Additional Information.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App ZZ Disenrollment Letter.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App RR Treatment Denial Letter and Appeal Notification.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App QQ Certification Denial Letter and Appeal.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App PP Enrollment Denial Letter and Appeal Notification.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App AAA Decert Letter Template Admin Error.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
App DDD Summary of Forms and Changes.docx	Supplementary Document	Uploaded 2022-01-06	Repair queued
0920-0891_SSB_Emergency_08212024.docx	Supporting Statement B	Uploaded 2024-08-22	Repair queued
0920-0891_SSA_Emergency_08212024.docx	Supporting Statement A	Uploaded 2024-08-22	Repair queued
60d FRN published.pdf	Supplementary Document	Uploaded 2022-01-06	Repair queued
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-10. NF PA3 Nucala.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-9. NF PA3 Methadone_09242018.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf	Supplementary Document	Uploaded 2018-10-09	Missing upstream
App Y-7. NF PA3 Epinephrine.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-6. NF PA3 Antipsychotics.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-5. NF PA3 Antiemetics.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-4. NF PA3 Antidepressants.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-3. NF PA3 Airway Drugs.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-2. PA3 Renewal Form.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App Y-1. General PA3 Form.pdf	Supplementary Document	Uploaded 2018-10-09	Repair queued
App TT Reimbursement Appeal Decision Letter.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App SS Summary of Forms and Changes_100918.docx	Supplementary Document	Uploaded 2018-10-09	Repair queued
App RR Decert Letter Template_Latency_Prostate_Cancer.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App PP Disenrollment and Decert Template.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App KK Translated Enroll Denial and Appeal Notif-Span.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App JJ - Translated 180 Day Request for Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App II - Translated 90 Day Request for Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App HH - Translated 60 Day Request for Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App GG - Translated 30 Day Request for Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App FF - Translated Initial Request for Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App EE IRB Determination.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App DD-1 60-day FRN 05112018.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App X Prior Authorization Form_Transplant.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App W Prior Authorization Form_Dental.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App V Prior Authorization Form_Standard.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App U WTC6 Medication Request.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App T WTC_5 Code or Procedure Request.pdf	Supplementary Document	Uploaded 2018-09-20	Repair queued
App Q 180 Day Letter Requesting Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App P 90 Day Letter Requesting Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App O 60 Day Letter Requesting Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App N 30 Day Letter Requesting Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App M Initial Letter Requesting Information.docx	Supplementary Document	Uploaded 2018-09-20	Repair queued
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx	Supplementary Document	Uploaded 2018-09-20	Available
Appendix A Legislation.docx	Supplementary Document	Uploaded 2014-12-18	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
270339	World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment	Form and Instruction	New
251030	Designated Representative Revocation Form	Form and Instruction	Unchanged
251023	WTC Health Program General HIPAA Authorization to Third Parties	Form and Instruction	Unchanged
251018	WTC Health Program HIPAA Authorization for Deceased Individuals	Form and Instruction	Unchanged
251017	Member Satisfaction Survey	Form and Instruction	Unchanged
233098	Petition for the Addition of a Health Condition (previously approved under 0920-0929)	Form and Instruction	Unchanged
233095	HIPAA Authorization to Release Information	Form and Instruction	Unchanged
218098	Designated Representative	Form and Instruction	Unchanged
218096	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	Form	Unchanged
214326	Survivor Eligibility Application	Form and Instruction	Unchanged
214325	Pentagon / Shanksville Responder	Form and Instruction	Unchanged
214324	General Responder Eligibility Application	Form and Instruction	Unchanged
214323	FDNY Responder Eligibility Application	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 202408-0920-004
Status: Received in OIRA	Previous ICR Reference No: 202402-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0891
Title: [NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/11/2024
Date Submitted to OIRA: 09/11/2024

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved	09/30/2025
Responses	29,719	28,977
Time Burden (Hours)	13,253	12,882
Cost Burden (Dollars)	146,417	146,417

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Abstract: The WTC Health Program is a limited healthcare program established by the James Zadroga 9/11 Health and Compensation Act of 2010. The goal of the Program is to provide monitoring and treatment to responders of the 9/11 terrorist attacks at the World Trade Center, Pentagon, and Shanksville, PA, as well as survivors in the New York City Area. The data collected contained within this OMB package are intended solely for determining eligibility and treatment. This Emergency ICR is submitted for the 0920-0891 WTCHP package so that data collection activities can begin immediately using a number of forms that permit enrollment of Pentagon/Shanksville, PA responders to the Program in response to an Interim Final Rule (IFR) that will be published September 11, 2024.

Emergency Justfication: On September 11, 2024, CDC plans to publish an Interim Final Rule that expands eligibility for the World Trade Center Health Program (WTCHP) to Pentagon and Shanksville responders. Failure to expedite enrollment processing could significantly harm public health, leaving these eligible individuals waiting for vital healthcare services. Emergency processing is imperative to prevent enrollment delays and potential adverse health outcomes. Therefore, expedited processing is not only necessary but crucial for ensuring timely access to health benefits for these responders. Submission of a full/standard Revision ICR will follow.

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Authorizing Statute(s): PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA86	Final or interim final rulemaking	89 FR 73592	09/11/2024

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	n/a	Clinic Selection Postcard
Designated Representative	n/a	Designated Representative Form
Designated Representative Revocation Form	0920-0891	Designated Representative Revocation Form
FDNY Responder Eligibility Application	n/a, n/a	FDNY Responder Eligibility Application ,   Screen shots of Web interface for electronic reporting option
General Responder Eligibility Application	n/a, n/a, n/a	General Responder (other than FDNY) Eligibility Application [English] ,   General Responder (other than FDNY) Eligibility Application [Spanish] ,   General Responder (other than FDNY) Eligibility Application [Polish]
HIPAA Authorization to Release Information	n/a	HIPAA Authorization Form to Release Information
Member Satisfaction Survey	0920-0891	Member Satisfaction Survey
Pentagon / Shanksville Responder	n/a	Pentagon / Shanksville Responder Eligibility Application
Petition for the Addition of a Health Condition (previously approved under 0920-0929)	n/a	Petition for the addition of health conditions
Survivor Eligibility Application	n/a, n/a, n/a, n/a	Eligibility Application for Survivors [English] ,   Eligibility Application for Survivors [Spanish] ,   Eligibility Application for Survivors [Polish] ,   Eligibility Application for Survivors [Chinese]
WTC Health Program General HIPAA Authorization to Third Parties	0920-0891, 0920-0891	WTC Health Program HIPAA Authorization - Third Parties ,   General HIPAA Authorization for Disclosures to Third Parties
WTC Health Program HIPAA Authorization for Deceased Individuals	0920-0891, 0920-0891	WTC Health Program HIPAA Authorization - Deceased Individuals ,   HIPAA Authorization for Disclosures Regarding Deceased Individuals
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment	0920-0891	WTCHP - Application for Enrollment: Pentagon/Shanksville Responder

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	29,719	28,977	0	742	0	0
Annual Time Burden (Hours)	13,253	12,882	0	371	0	0
Annual Cost Burden (Dollars)	146,417	146,417	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Emergency Revision of 0920-0891 package results in increase of 371 burden hours to permit enrollment of Pentagon/Shanksville, PA responders to the WTCHP.

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Annual Cost to Federal Government: $323,763

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/11/2024

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