Designated Representative

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

Documents and Forms

Document Name Document Type
Designated Representative Form and Instruction
Designated Representative Form App LL WTC Designated Representative.docx Form and Instruction
Designated Representative Form App LL WTC Designated Representative.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Designated Representative	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	Designated Representative Form	App LL WTC Designated Representative.docx		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: 1,300	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	1,300	1,300
Annual IC Time Burden (Hours)	325	325
Annual IC Cost Burden (Dollars)	5,915	5,915

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.