Information Collection

Petition for the Addition of a Health Condition (previously approved under 0920-0929)

IC 233098 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⚠️ Notice: This information collection may be referencing outdated material.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
Petition for the Addition of a Health Condition (previously approved under 0920-0929)	Form and Instruction
Petition for the addition of health conditions App NN Petition for Addition of a New WTC Condition.docx	Form and Instruction
Petition for the addition of health conditions App NN Petition for Addition of a New WTC Condition.docx	Form and Instruction

IC Title:

Petition for the Addition of a Health Condition (previously approved under 0920-0929)

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	Petition for the addition of health conditions	App NN Petition for Addition of a New WTC Condition.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records HHS/CDC/NIOSH

FR Citation: 76 FR 34706

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	1,260	1,260

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.