Survivor Eligibility Application

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

OMB: 0920-0891

IC ID: 214326

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Survivor Eligibility Application
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx No   Paper Only
Form and Instruction n/a Eligibility Application for Survivors [Spanish] App I Survivors Spanish.docx No   Paper Only
Form and Instruction n/a Eligibility Application for Survivors [Polish] App J Survivors Polish.docx No   Paper Only
Form and Instruction n/a Eligibility Application for Survivors [Chinese] App K Survivors Chinese.docx No   Paper Only

Health Health Care Services

09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH  76 FR 34706

9,240 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 9,240 0 0 0 0 9,240
Annual IC Time Burden (Hours) 4,620 0 0 0 0 4,620
Annual IC Cost Burden (Dollars) 55,440 0 0 0 0 55,440

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