OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

OMB 0920-0891 ยท HHS/CDC.

OMB 0920-0891

The WTC Health Program is a limited healthcare program established by the James Zadroga 9/11 Health and Compensation Act of 2010. The goal of the Program is to provide monitoring and treatment to responders of the 9/11 terrorist attacks at the World Trade Center, Pentagon, and Shanksville, PA, as well as survivors in the New York City Area. The data collected contained within this OMB package are intended solely for determining eligibility and treatment. This Revision ICR is submitted for the 0920-0891 WTCHP package for enrollment of Pentagon/Shanksville, PA responders to the Program and to add Youth Research Cohort Registration Forms. Overall burden associated with this data collection will increase to 14,332 hours.

The latest form for [NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement expires 2028-05-31 and is listed under ICR 202502-0920-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 0920-0891 WTCHP Youth Research Cohort HIPAA Authorization Form_10FEB2025Form and Instruction
Form 0920-0891 Youth Research Cohort Registration HIPAA AuthorizationForm and Instruction
Form 0920-0891 WTCHP Youth Research Cohort Registration Portal_10FEB2025Form and Instruction
Form 0920-0891 Youth Research Cohort Registration PortalForm and Instruction
Form 0920-0891 WTCHP - Application for Enrollment: Pentagon/Shanksville ResponderForm and Instruction
Form 0920-0891 World Trade Center Health Program Pentagon/Shanksville Responder Application for EnrollmentForm and Instruction
Form 0920-0891 WTCHP Designated Representatives Revocation Form_10FEB2025Form and Instruction
Form 0920-0891 Designated Representative Revocation FormForm and Instruction
Form 0920-0891 Designated Representative Revocation FormForm and Instruction
Form 0920-0891 WTCHP HIPAA Authorization Third Parties_10FEB2025Form and Instruction
Form 0920-0891 General HIPAA Authorization for Disclosures to Third PartiesForm and Instruction
Form 0920-0891 WTC Health Program HIPAA Authorization - Third PartiesForm and Instruction
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third PartiesForm and Instruction
Form 0920-0891 WTCHP HIPAA Authorization Deceased Individuals_10FEB2025Form and Instruction
Form 0920-0891 HIPAA Authorization for Disclosures Regarding Deceased IndividualsForm and Instruction
Form 0920-0891 WTC Health Program HIPAA Authorization - Deceased IndividualsForm and Instruction
Form 0920-0891 Member Satisfaction SurveyForm and Instruction
Form 0920-0891 Member Satisfaction SurveyForm and Instruction
Form 0920-0891 WTCHP Petition for Designation of New Condition Form_10FEB2025Form and Instruction
Petition for the addition of health conditionsForm and Instruction
Petition for the Addition of a Health ConditionForm and Instruction
Form 0920-0891 WTCHP Designated Representative HIPAA Authorization_10FEB2025Form and Instruction
HIPAA Authorization Form to Release InformationForm and Instruction
HIPAA Authorization to Release InformationForm and Instruction
Form 0920-0891 WTCHP Designated Representative Form_10FEB2025Form and Instruction
Designated Representative FormForm and Instruction
Form 0920-0891 WTCHP Clinic Selection Postcard_10FEB2025Form and Instruction
Clinic Selection PostcardForm
Form 0920-0891 WTCHP Survivor Application_Eng 19FEB2025Form and Instruction
Form 0920-0891 WTCHP Survivor Application_Eng_10FEB2025Form and Instruction
Eligibility Application for Survivors [English]Form and Instruction
Survivor Eligibility ApplicationForm and Instruction
Form 0920-0891 WTCHP Pentagon_Shanksville Application 19FEB2025Form and Instruction
Form 0920-0891 WTCHP Pentagon_Shanksville Application_10FEB2025Form and Instruction
Pentagon / Shanksville Responder Eligibility ApplicationForm and Instruction
Pentagon / Shanksville ResponderForm and Instruction
Form 0920-0891 WTCHP General Responder Application_NonFDNY_Eng_19FEB2025Form and Instruction
Form 0920-0891 WTCHP General Responder Application_NonFDNY_Eng_10FEB2025Form and Instruction
General Responder (other than FDNY) Eligibility Application [English]Form and Instruction
General Responder Eligibility ApplicationForm and Instruction
Form 0920-0891 WTCHP FDNY Responder Application 19FEB2025Form and Instruction
Form 0920-0891 WTCHP FDNY Responder Application 10FEB2025Form and Instruction
Screen shots of Web interface for electronic reporting optionForm
FDNY Responder Eligibility ApplicationForm and Instruction
FDNY Responder Eligibility ApplicationForm and Instruction
App TT-1a 60-day FRN Comment.pdf (document unavailable)Public Comments
App TT-1 60-day FRN Published.pdfSupplementary Document
0920-0891_EmergencyRequest_Memo.pdfSupplementary Document
0920-0891_EmergencyReviewRequest_memo.docxSupplementary Document
Request for Nonsubstantive Change.docxJustification for No Material/Nonsubstantive Change
App Y 180 Day Letter Reminder for Additional Information.docxSupplementary Document
App X Survivor 90 Day Suspend Letter.docxSupplementary Document
App W 60 Day Suspend Letter.docxSupplementary Document
App V 30 Day Suspend Letter.docxSupplementary Document
App U Initial Request for Additional Information.docxSupplementary Document
App ZZ Disenrollment Letter.docxSupplementary Document
App RR Treatment Denial Letter and Appeal Notification.docxSupplementary Document
App QQ Certification Denial Letter and Appeal.docxSupplementary Document
App PP Enrollment Denial Letter and Appeal Notification.docxSupplementary Document
App AAA Decert Letter Template Admin Error.docxSupplementary Document
App DDD Summary of Forms and Changes.docxSupplementary Document
WTCHP-SSB-Update_FINAL_020725.docxSupporting Statement B
WTCHP-SSA-Update_FINAL_020725.docxSupporting Statement A
60d FRN published.pdfSupplementary Document
App Y-11. NF PA3 Opioid Deterrent_09242018.pdfSupplementary Document
App Y-10. NF PA3 Nucala.pdfSupplementary Document
App Y-9. NF PA3 Methadone_09242018.pdfSupplementary Document
App Y-8. NF PA3 Diabetes Insulin_09242018.pdfSupplementary Document
App Y-7. NF PA3 Epinephrine.pdfSupplementary Document
App Y-6. NF PA3 Antipsychotics.pdfSupplementary Document
App Y-5. NF PA3 Antiemetics.pdfSupplementary Document
App Y-4. NF PA3 Antidepressants.pdfSupplementary Document
App Y-3. NF PA3 Airway Drugs.pdfSupplementary Document
App Y-2. PA3 Renewal Form.pdfSupplementary Document
App Y-1. General PA3 Form.pdfSupplementary Document
App TT Reimbursement Appeal Decision Letter.docxSupplementary Document
CDC-WTCHP-1741-PTA-08-28-2018-100....pdfSupplementary Document
App SS Summary of Forms and Changes_100918.docxSupplementary Document
App RR Decert Letter Template_Latency_Prostate_Cancer.docxSupplementary Document
App PP Disenrollment and Decert Template.docxSupplementary Document
App KK Translated Enroll Denial and Appeal Notif-Span.docxSupplementary Document
App JJ - Translated 180 Day Request for Information.docxSupplementary Document
App II - Translated 90 Day Request for Information.docxSupplementary Document
App HH - Translated 60 Day Request for Information.docxSupplementary Document
App GG - Translated 30 Day Request for Information.docxSupplementary Document
App FF - Translated Initial Request for Information.docxSupplementary Document
App EE IRB Determination.pdfSupplementary Document
App DD-1 60-day FRN 05112018.pdfSupplementary Document
App X Prior Authorization Form_Transplant.pdfSupplementary Document
App W Prior Authorization Form_Dental.pdfSupplementary Document
App V Prior Authorization Form_Standard.pdf (document unavailable)Supplementary Document
App V Prior Authorization Form_Standard.pdf (document unavailable) Supplementary Document
App U WTC6 Medication Request.pdf (document unavailable)Supplementary Document
App U WTC6 Medication Request.pdf (document unavailable) Supplementary Document
App T WTC_5 Code or Procedure Request.pdfSupplementary Document
App Q 180 Day Letter Requesting Information.docxSupplementary Document
App P 90 Day Letter Requesting Information.docxSupplementary Document
App O 60 Day Letter Requesting Information.docxSupplementary Document
App N 30 Day Letter Requesting Information.docx (document unavailable)Supplementary Document
App N 30 Day Letter Requesting Information.docx (document unavailable) Supplementary Document
App M Initial Letter Requesting Information.docxSupplementary Document
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docxSupplementary Document
Appendix A Legislation.docxSupplementary Document
Youth Research Cohort Registration HIPAA Authorization Form and Instruction
Youth Research Cohort Registration HIPAA Authorization Form and Instruction
Youth Research Cohort Registration Portal Form and Instruction
Youth Research Cohort Registration Portal Form and Instruction
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction
Designated Representative Revocation Form Form and Instruction
Designated Representative Revocation Form Form and Instruction
Designated Representative Revocation Form Form and Instruction
WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
Member Satisfaction Survey Form and Instruction
Member Satisfaction Survey Form and Instruction
Petition for the Addition of a Health Condition Form and Instruction
Petition for the Addition of a Health Condition Form and Instruction
Petition for the Addition of a Health Condition Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
Designated Representative Form Form and Instruction
Designated Representative Form Form and Instruction
Designated Representative Form Form and Instruction
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form and Instruction
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Survivor Eligibility Application Form and Instruction
Survivor Eligibility Application Form and Instruction
Survivor Eligibility Application Form and Instruction
Survivor Eligibility Application Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
General Responder Eligibility Application Form and Instruction
General Responder Eligibility Application Form and Instruction
General Responder Eligibility Application Form and Instruction
General Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form
FDNY Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202502-0920-001 Reinstatement with change of a previously approved collection 2025-03-28
202408-0920-004 Revision of a currently approved collection 2024-09-11 Approved with change
202402-0920-004 No material or nonsubstantive change to a currently approved collection 2024-02-13 Approved without change
202201-0920-002 Reinstatement with change of a previously approved collection 2022-01-06 Approved without change
201703-0920-004 Revision of a currently approved collection 2018-09-25 Approved without change
201412-0920-012 Revision of a currently approved collection 2014-12-30 Approved with change
201406-0920-001 No material or nonsubstantive change to a currently approved collection 2014-06-05 Approved without change
201307-0920-001 No material or nonsubstantive change to a currently approved collection 2013-07-01 Approved without change
201112-0920-016 No material or nonsubstantive change to a currently approved collection 2011-12-27 Approved without change
201112-0920-010 Extension without change of a currently approved collection 2011-12-16 Approved without change
201112-0920-007 Revision of a currently approved collection 2011-12-13 Approved without change
201106-0920-016 New collection (Request for a new OMB Control Number) 2011-06-27 Preapproved

OMB Details

FDNY Responder Eligibility Application

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form 0920-0891WTCHP FDNY Responder Application 10FEB2025N/AForm and instruction
Form n/aScreen shots of Web interface for electronic reporting optionFillable FileableForm
Form n/aFDNY Responder Eligibility ApplicationFillable FileableForm and instruction
Form 0920-0891WTCHP FDNY Responder Application 19FEB2025N/AForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.