Information Collection

Clinic Selection Postcard for new general responders in NY/NJ to select a clinic

IC 218096 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	Form
Clinic Selection Postcard Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	Form
Form 0920-0891 WTCHP Clinic Selection Postcard_10FEB2025 Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	Form and Instruction
Clinic Selection Postcard App R Clinic Selection Postcard.pdf	Form
Clinic Selection Postcard App R Clinic Selection Postcard.pdf	Form
0920-0891 WTCHP Clinic Selection Postcard_10FEB2025 App J-Clinic Selection Postcard.pdf	Form and Instruction
0920-0891 WTCHP Clinic Selection Postcard_10FEB2025 App J-Clinic Selection Postcard.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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	n/a				No		Paper Only
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: 3,830

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	3,830	3,830
Annual IC Time Burden (Hours)	958	958
Annual IC Cost Burden (Dollars)	17,427	17,427

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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