Information Collection

World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment

IC 270339 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0891 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment	Form and Instruction
0920-0891 WTCHP - Application for Enrollment: Pentagon/Shanksville pent-shank-draft enrollment form.pdf	Form and Instruction
0920-0891 WTCHP - Application for Enrollment: Pentagon/Shanksville pent-shank-draft enrollment form.pdf	Form and Instruction

IC Title:

World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	0920-0891	WTCHP - Application for Enrollment: Pentagon/Shanksville Responder	pent-shank-draft enrollment form.pdf	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 742

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	742	742
Annual IC Time Burden (Hours)	371	371
Annual IC Cost Burden (Dollars)	0	0

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.