Information Collection

Designated Representative Revocation Form

IC 251030 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0891 Designated Representative Revocation Form	Form and Instruction
Form 0920-0891 Designated Representative Revocation Form Designated Representative Revocation Form	Form and Instruction
Form 0920-0891 WTCHP Designated Representatives Revocation Form_10FEB2025 Designated Representative Revocation Form	Form and Instruction
0920-0891 Designated Representative Revocation Form App Q Designated Representative Revocation DRAFT.docx	Form and Instruction
0920-0891 Designated Representative Revocation Form App Q Designated Representative Revocation DRAFT.docx	Form and Instruction
0920-0891 WTCHP Designated Representatives Revocation Form_10FEB20 App P-Designated Representative Revocation Form.pdf	Form and Instruction
0920-0891 WTCHP Designated Representatives Revocation Form_10FEB20 App P-Designated Representative Revocation 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	0920-0891			NA	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 Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records

FR Citation: 76 FR 34706

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

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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