OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

World Trade Center Health Program Enrollment & Appeals - Pentagon & Shanksville, PA Responders

ICR 201304-0920-001 · OMB 0920-0962 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Medical Travel Refund Request Form New Repair queued
Form SF 3881 SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form Form New Available
WTC Pentagon & Shanksville, PA Eligibility Application Form New Repair queued
Appendix A Zadroga Act.docx Supplementary Document Uploaded 2013-03-31 Available
Denial Letter Health Condition F-1.docx Supplementary Document Uploaded 2013-03-31 Available
Denial Letter G-1 - Treatment.docx Supplementary Document Uploaded 2013-03-31 Available
Denial Letter C-1 - Eligibility.docx Supplementary Document Uploaded 2013-03-31 Available
World Trade Center Supptg Stmt A PA_VA application 3.29.13.docx Supporting Statement A Uploaded 2013-03-31 Available
IC Document Collections
IC IDCollectionTypeStatusForm
206325 Medical Travel Refund Request Form New
206324 Outpatient Pharmacies Other-Document New
206323 SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form Form New
206322 Appeals regarding Certification of Health Conditions Other-Document New
206321 Appeals Regarding Treatment Other-Document New
206320 Appeals regarding Eligibility Denial Other-Document New
206319 WTC Pentagon & Shanksville, PA Eligibility Application Form New
ICR Details
0920-0962 201304-0920-001
Historical Active
HHS/CDC 19218
World Trade Center Health Program Enrollment & Appeals - Pentagon & Shanksville, PA Responders
New collection (Request for a new OMB Control Number)   No
Emergency 05/01/2013
Approved without change 04/10/2013
Retrieve Notice of Action (NOA) 04/01/2013
  Inventory as of this Action Requested Previously Approved
10/31/2013 6 Months From Approved
2,690 0 0
832 0 0
0 0 0
The National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention seeks approval to expand data collection under the World Trade Center Health Program to include responders and volunteers at the Pentagon and in Shanksville, Pennsylvania.
This emergency clearance is essential for Pentaton and Shanksville, PA responders who wish to apply to the World Trade Center (WTC)Program or appeal a decision by the WTC program. Eligibility criteria are being promulgated by Interim Final Rule which will be effective on May 1, 2013.
US Code: 42 USC 88 Name of Law: James Zadroga Act
  
US Code: 42 USC 88 Name of Law: James Zadroga Act
0920-AA48 Final or interim final rulemaking 78 FR 18855 03/28/2013
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,690 0 2,690 0 0 0
Annual Time Burden (Hours) 832 0 832 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
This is a request for an Emergency Clearance.
$64,425
No
No
No
No
No
Uncollected
Carol Walker 4046394773
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/01/2013