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

ICR 202408-0920-004

OMB: 0920-0891

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
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Form and Instruction
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Form and Instruction
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Supplementary Document
2024-08-22
Justification for No Material/Nonsubstantive Change
2024-02-12
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supporting Statement B
2024-08-22
Supporting Statement A
2024-08-22
Supplementary Document
2022-01-06
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-10-09
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2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2014-12-18
ICR Details
0920-0891 202408-0920-004
Received in OIRA 202402-0920-004
HHS/CDC 0920-0891
[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement
Revision of a currently approved collection   No
Emergency 09/11/2024
09/11/2024
  Requested Previously Approved
6 Months From Approved 09/30/2025
29,719 28,977
13,253 12,882
146,417 146,417

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.
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.

PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  
None

0920-AA86 Final or interim final rulemaking 89 FR 73592 09/11/2024

No

13
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

  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
Yes
Changing Regulations
No
Emergency Revision of 0920-0891 package results in increase of 371 burden hours to permit enrollment of Pentagon/Shanksville, PA responders to the WTCHP.

$323,763
No
    Yes
    Yes
No
No
No
No
Jeffrey Zirger 404 639-7118 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/11/2024


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