Information Collection

FDNY Responder Eligibility Application

IC 214323 under ICR 202408-0920-004 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.