Information Collection

Survivor Eligibility Application

IC 214326 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survivor Eligibility Application	Form and Instruction
Eligibility Application for Survivors [English] Survivor Eligibility Application	Form and Instruction
Form 0920-0891 WTCHP Survivor Application_Eng_10FEB2025 Survivor Eligibility Application	Form and Instruction
Form 0920-0891 WTCHP Survivor Application_Eng 19FEB2025 Survivor Eligibility Application	Form and Instruction
Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx	Form and Instruction
Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx	Form and Instruction
0920-0891 WTCHP Survivor Application_Eng_10FEB2025 App F-WTCHP Survivor App for Enrollment_Eng.pdf	Form and Instruction
0920-0891 WTCHP Survivor Application_Eng_10FEB2025 App F-WTCHP Survivor App for Enrollment_Eng.pdf	Form and Instruction
0920-0891 WTCHP Survivor Application_Eng 19FEB2025 App F-WTCHP Survivor Application English_FINAL.pdf	Form and Instruction
0920-0891 WTCHP Survivor Application_Eng 19FEB2025 App F-WTCHP Survivor Application English_FINAL.pdf	Form and Instruction
App G-WTCHP Survivor App for Enrollment_Span.pdf WTCHP Survivor Application_Span_10FEB2025	IC Document
App G-WTCHP Survivor App for Enrollment_Span.pdf WTCHP Survivor Application_Span_10FEB2025	IC Document
App H-WTCHP Survivor Application Polish.pdf WTCHP Survivor Application_Polish_10FEB2025	IC Document
App H-WTCHP Survivor Application Polish.pdf WTCHP Survivor Application_Polish_10FEB2025	IC Document
App I-WTCHP Survivor Application Chinese.pdf WTCHP Survivor Application_Chinese_10FEB2025	IC Document
App I-WTCHP Survivor Application Chinese.pdf WTCHP Survivor Application_Chinese_10FEB2025	IC Document
App G-WTCHP Survivor Application Spanish_FINAL.pdf WTCHP Survivor Application_Span 19FEB2025	IC Document
App G-WTCHP Survivor Application Spanish_FINAL.pdf WTCHP Survivor Application_Span 19FEB2025	IC Document
App H-WTCHP Survivor Application Polish_FINAL.pdf WTCHP Survivor Application_Polish 19FEB2025	IC Document
App H-WTCHP Survivor Application Polish_FINAL.pdf WTCHP Survivor Application_Polish 19FEB2025	IC Document
App I-WTCHP Survivor Application Chinese_FINAL.pdf WTCHP Survivor Application_Chinese 19FEB2025	IC Document
App I-WTCHP Survivor Application Chinese_FINAL.pdf WTCHP Survivor Application_Chinese 19FEB2025	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Survivor 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:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a		No		Paper Only
Form and Instruction	0920-0891	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	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: 9,240

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,240	9,240
Annual IC Time Burden (Hours)	4,620	4,620
Annual IC Cost Burden (Dollars)	55,440	55,440

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
WTCHP Survivor Application_Span_10FEB2025		02/10/2025
WTCHP Survivor Application_Polish_10FEB2025		02/10/2025
WTCHP Survivor Application_Chinese_10FEB2025		02/10/2025
WTCHP Survivor Application_Span 19FEB2025		02/24/2025
WTCHP Survivor Application_Polish 19FEB2025		02/24/2025
WTCHP Survivor Application_Chinese 19FEB2025		02/24/2025

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

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