FDNY Responder Eligibility Application

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

Documents and Forms

Document Name Document Type
FDNY Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application App C FDNYResponderEligibility.docx Form and Instruction
FDNY Responder Eligibility Application App C FDNYResponderEligibility.docx Form and Instruction
Screen shots of Web interface for electronic reporting o App L Web Screen Shots.docx Form
Screen shots of Web interface for electronic reporting o App L Web Screen Shots.docx Form

Information Collection (IC) Details

IC Title:	FDNY 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	FDNY Responder Eligibility Application	App C FDNYResponderEligibility.docx		Yes	Yes	Fillable Fileable
Form	n/a	Screen shots of Web interface for electronic reporting option	App L Web Screen Shots.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: 140	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	140	140
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	1,701	1,701

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.