Information Collection

FDNY Responder Eligibility Application

IC 214323 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FDNY Responder Eligibility Application	Form and Instruction
FDNY Responder Eligibility Application FDNY Responder Eligibility Application	Form and Instruction
Screen shots of Web interface for electronic reporting option FDNY Responder Eligibility Application	Form
Form 0920-0891 WTCHP FDNY Responder Application 10FEB2025 FDNY Responder Eligibility Application	Form and Instruction
Form 0920-0891 WTCHP FDNY Responder Application 19FEB2025 FDNY Responder Eligibility Application	Form and Instruction
FDNY Responder Eligibility Application App C FDNYResponderEligibility.docx	Form and Instruction
FDNY Responder Eligibility Application App C FDNYResponderEligibility.docx	Form and Instruction
Screen shots of Web interface for electronic reporting o App L Web Screen Shots.docx	Form
Screen shots of Web interface for electronic reporting o App L Web Screen Shots.docx	Form
0920-0891 WTCHP FDNY Responder Application 10FEB2025 App A-WTCHP FDNY Responder.pdf	Form and Instruction
0920-0891 WTCHP FDNY Responder Application 10FEB2025 App A-WTCHP FDNY Responder.pdf	Form and Instruction
0920-0891 WTCHP FDNY Responder Application 19FEB2025 App A-WTCHP FDNY Responder_FINAL.pdf	Form and Instruction
0920-0891 WTCHP FDNY Responder Application 19FEB2025 App A-WTCHP FDNY Responder_FINAL.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a		Yes	Yes	Fillable Fileable
Form	n/a		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	N/A	Yes	Yes	Fillable Fileable

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: 140

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	1,701	1,701

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.

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