Clinic Selection Postcard for new general responders in NY/NJ to select a clinic

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

Documents and Forms

Document Name Document Type
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Clinic Selection Postcard App R Clinic Selection Postcard.pdf Form
Clinic Selection Postcard App R Clinic Selection Postcard.pdf Form

Information Collection (IC) Details

IC Title:	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	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	n/a	Clinic Selection Postcard	App R Clinic Selection Postcard.pdf		No		Paper Only

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: 3,830	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,830	3,830
Annual IC Time Burden (Hours)	958	958
Annual IC Cost Burden (Dollars)	17,427	17,427

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.