Information Collection

Pentagon / Shanksville Responder

IC 214325 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pentagon / Shanksville Responder	Form and Instruction
Pentagon / Shanksville Responder Eligibility Application Pentagon / Shanksville Responder	Form and Instruction
Form 0920-0891 WTCHP Pentagon_Shanksville Application_10FEB2025 Pentagon / Shanksville Responder	Form and Instruction
Form 0920-0891 WTCHP Pentagon_Shanksville Application 19FEB2025 Pentagon / Shanksville Responder	Form and Instruction
Pentagon / Shanksville Responder Eligibility Application App G Pentagon-Shanksville Application.docx	Form and Instruction
Pentagon / Shanksville Responder Eligibility Application App G Pentagon-Shanksville Application.docx	Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application_10FEB2025 App E-WTCHP Pentagon Shanksville App for Enrollment.pdf	Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application_10FEB2025 App E-WTCHP Pentagon Shanksville App for Enrollment.pdf	Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application 19FEB2025 App E-WTCHP Pentagon Shanksville Enrollment_FINAL.pdf	Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application 19FEB2025 App E-WTCHP Pentagon Shanksville Enrollment_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 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: 742

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	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	742	500	242
Annual IC Time Burden (Hours)	371	250	121
Annual IC Cost Burden (Dollars)	6,752	4,550	2,202

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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