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

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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.