Information Collection

Petition for the Addition of a Health Condition

IC 233098 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Petition for the Addition of a Health Condition	Form and Instruction
Petition for the addition of health conditions Petition for the Addition of a Health Condition	Form and Instruction
Form 0920-0891 WTCHP Petition for Designation of New Condition Form_10FEB2025 Petition for the Addition of a Health Condition	Form and Instruction
Petition for the addition of health conditions App NN Petition for Addition of a New WTC Condition.docx	Form and Instruction
Petition for the addition of health conditions App NN Petition for Addition of a New WTC Condition.docx	Form and Instruction
0920-0891 WTCHP Petition for Designation of New Condition Form_10F App M-Petition for Addition New WTC-Related Health Condition Form.pdf	Form and Instruction
0920-0891 WTCHP Petition for Designation of New Condition Form_10F App M-Petition for Addition New WTC-Related Health Condition Form.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 and Instruction	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 Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records HHS/CDC/NIOSH

FR Citation: 76 FR 34706

Number of Respondents: 35

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	35	35
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	1,260	1,260

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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