OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202502-0920-001 · OMB 0920-0891 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-0891 Youth Research Cohort Registration HIPAA Authorization Form and Instruction New Repair queued
Form 0920-0891 Youth Research Cohort Registration Portal Form and Instruction New Repair queued
Form 0920-0891 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction Removed Missing upstream
Form 0920-0891 Designated Representative Revocation Form Form and Instruction Modified Repair queued
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Modified Repair queued
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Modified Available
Form 0920-0891 Member Satisfaction Survey Form and Instruction Removed Repair queued
Petition for the Addition of a Health Condition Form and Instruction Modified Repair queued
HIPAA Authorization to Release Information Form and Instruction Modified Repair queued
Designated Representative Form Form and Instruction Modified Available
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Modified Repair queued
Survivor Eligibility Application Form and Instruction Modified Repair queued
Pentagon / Shanksville Responder Form and Instruction Modified Repair queued
General Responder Eligibility Application Form and Instruction Modified Repair queued
FDNY Responder Eligibility Application Form and Instruction Modified Repair queued
App TT-1 60-day FRN Published.pdf Supplementary Document Uploaded 2025-02-10 Repair queued
0920-0891_EmergencyRequest_Memo.pdf Supplementary Document Uploaded 2024-09-12 Repair queued
0920-0891_EmergencyReviewRequest_memo.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-02-12 Repair queued
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App X Survivor 90 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App W 60 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Available
App V 30 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App U Initial Request for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App ZZ Disenrollment Letter.docx Supplementary Document Uploaded 2022-01-06 Missing upstream
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App QQ Certification Denial Letter and Appeal.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App AAA Decert Letter Template Admin Error.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App DDD Summary of Forms and Changes.docx Supplementary Document Uploaded 2022-01-06 Repair queued
WTCHP-SSB-Update_FINAL_020725.docx Supporting Statement B Uploaded 2025-02-10 Repair queued
WTCHP-SSA-Update_FINAL_020725.docx Supporting Statement A Uploaded 2025-02-10 Repair queued
60d FRN published.pdf Supplementary Document Uploaded 2022-01-06 Repair queued
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-10. NF PA3 Nucala.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document Uploaded 2018-10-09 Available
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-2. PA3 Renewal Form.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-1. General PA3 Form.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document Uploaded 2018-09-20 Repair queued
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App SS Summary of Forms and Changes_100918.docx Supplementary Document Uploaded 2018-10-09 Repair queued
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App PP Disenrollment and Decert Template.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App JJ - Translated 180 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App II - Translated 90 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App HH - Translated 60 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App GG - Translated 30 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App FF - Translated Initial Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App EE IRB Determination.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App DD-1 60-day FRN 05112018.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App X Prior Authorization Form_Transplant.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App W Prior Authorization Form_Dental.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App V Prior Authorization Form_Standard.pdf Supplementary Document Uploaded 2018-09-20 Available
App U WTC6 Medication Request.pdf Supplementary Document Uploaded 2018-09-20 Available
App T WTC_5 Code or Procedure Request.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App Q 180 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App P 90 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App O 60 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App N 30 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Available
App M Initial Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Available
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document Uploaded 2018-09-20 Repair queued
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
273995 Youth Research Cohort Registration HIPAA Authorization Form and Instruction New
273994 Youth Research Cohort Registration Portal Form and Instruction New
270339 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction Removed
251030 Designated Representative Revocation Form Form and Instruction Modified
251023 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Modified
251018 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Modified
251017 Member Satisfaction Survey Form and Instruction Removed
233098 Petition for the Addition of a Health Condition Form and Instruction Modified
233095 HIPAA Authorization to Release Information Form and Instruction Modified
218098 Designated Representative Form Form and Instruction Modified
218096 Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Modified
214326 Survivor Eligibility Application Form and Instruction Modified
214325 Pentagon / Shanksville Responder Form and Instruction Modified
214324 General Responder Eligibility Application Form and Instruction Modified
214323 FDNY Responder Eligibility Application Form and Instruction Modified
ICR Details
StatusReceived in OIRA
Agency/SubagencyHHS/CDC
OMB Control No0920-0891
Type of Information CollectionReinstatement with change of a previously approved collection
Previous ICR Reference No202408-0920-004
Agency Tracking No0920-0891
Date Submitted to OIRA1969-12-31
Requested Expiration Date1969-12-31