Information Collection

Designated Representative Form

IC 218098 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Document Name Document Type
Designated Representative Form Form and Instruction
Designated Representative Form App LL WTC Designated Representative.docx Form and Instruction
Designated Representative Form App LL WTC Designated Representative.docx Form and Instruction
0920-0891 WTCHP Designated Representative Form_10FEB2025 App K-Designated Representative Form.pdf Form and Instruction
0920-0891 WTCHP Designated Representative Form_10FEB2025 App K-Designated Representative Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Designated Representative Form	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	Designated Representative Form	App LL WTC Designated Representative.docx		No		Paper Only
Form and Instruction	0920-0891	WTCHP Designated Representative Form_10FEB2025	App K-Designated Representative Form.pdf	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: 1,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,300	1,300
Annual IC Time Burden (Hours)	325	325
Annual IC Cost Burden (Dollars)	5,915	5,915

Documents for IC

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.