Information Collection

General Responder Eligibility Application

IC 214324 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Document Name Document Type
General Responder Eligibility Application Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App D NYCResponderEligibility.docx Form and Instruction
General Responder (other than FDNY) Eligibility Applicat App D NYCResponderEligibility.docx Form and Instruction
0920-0891 WTCHP General Responder Application_NonFDNY_Eng_10FEB202 App B-WTCHP Responder App for Enrollment other than FDNY Eng.pdf Form and Instruction
0920-0891 WTCHP General Responder Application_NonFDNY_Eng_10FEB202 App B-WTCHP Responder App for Enrollment other than FDNY Eng.pdf Form and Instruction
0920-0891 WTCHP General Responder Application_NonFDNY_Eng_19FEB202 App B-WTCHP Responder Enrollment Non-FDNY English_FINAL.pdf Form and Instruction
0920-0891 WTCHP General Responder Application_NonFDNY_Eng_19FEB202 App B-WTCHP Responder Enrollment Non-FDNY English_FINAL.pdf Form and Instruction
App C-WTCHP Responder App for Enrollment other than FDNY Span.pdf WTCHP General Responder Application_NonFDNY_Span_10FEB2025 IC Document
App C-WTCHP Responder App for Enrollment other than FDNY Span.pdf WTCHP General Responder Application_NonFDNY_Span_10FEB2025 IC Document
App D-WTCHP Responder App for Enrollment other than FDNY Polish.pdf WTCHP General Responder Application_NonFDNY_Polish_10FEB2025 IC Document
App D-WTCHP Responder App for Enrollment other than FDNY Polish.pdf WTCHP General Responder Application_NonFDNY_Polish_10FEB2025 IC Document
App C-WTCHP Responder Enrollment Non-FDNY Spanish_FINAL.pdf WTCHP General Responder Application_NonFDNY_Span_10FEB2025 IC Document
App C-WTCHP Responder Enrollment Non-FDNY Spanish_FINAL.pdf WTCHP General Responder Application_NonFDNY_Span_10FEB2025 IC Document
App D-WTCHP Responder Enrollment Non-FDNY Polish_FINAL.pdf WTCHP General Responder Application_NonFDNY_Polish_19FEB2025 IC Document
App D-WTCHP Responder Enrollment Non-FDNY Polish_FINAL.pdf WTCHP General Responder Application_NonFDNY_Polish_19FEB2025 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	General Responder Eligibility Application	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	General Responder (other than FDNY) Eligibility Application [English]	App D NYCResponderEligibility.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	WTCHP General Responder Application_NonFDNY_Eng_10FEB2025	App B-WTCHP Responder App for Enrollment other than FDNY Eng.pdf	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	WTCHP General Responder Application_NonFDNY_Eng_19FEB2025	App B-WTCHP Responder Enrollment Non-FDNY English_FINAL.pdf	N/A	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: 6,215	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	6,215	6,215
Annual IC Time Burden (Hours)	3,108	3,108
Annual IC Cost Burden (Dollars)	56,557	56,557

Documents for IC

Title	Document	Date Uploaded
WTCHP General Responder Application_NonFDNY_Span_10FEB2025	App C-WTCHP Responder App for Enrollment other than FDNY Span.pdf	02/10/2025
WTCHP General Responder Application_NonFDNY_Polish_10FEB2025	App D-WTCHP Responder App for Enrollment other than FDNY Polish.pdf	02/10/2025
WTCHP General Responder Application_NonFDNY_Span_10FEB2025	App C-WTCHP Responder Enrollment Non-FDNY Spanish_FINAL.pdf	02/19/2025
WTCHP General Responder Application_NonFDNY_Polish_19FEB2025	App D-WTCHP Responder Enrollment Non-FDNY Polish_FINAL.pdf	02/19/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.