OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

World Trade Center Enrollment & Appeals - Pentagon & Shanksville

ICR 201311-0920-009 · OMB 0920-1001 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Responder Travel Refund Request Form New Available
Responder Eligibility Application Form and Instruction New Repair queued
Supporting Statement B 11.1.13.docx Supporting Statement B Uploaded 2013-11-07 Available
Appendix K.pdf Supplementary Document Uploaded 2013-11-07 Available
Appendix J.pdf Supplementary Document Uploaded 2013-11-07 Available
Appendix I.docx Supplementary Document Uploaded 2013-11-07 Repair queued
60 day FRN.pdf Supplementary Document Uploaded 2013-11-07 Repair queued
Appendix A Zadroga Act.docx Supplementary Document Uploaded 2013-11-07 Available
Denial Letter F-1 - Treatment.docx Supplementary Document Uploaded 2013-11-07 Available
Denial Letter Health Condition E-1.docx Supplementary Document Uploaded 2013-11-07 Available
Denial Letter C-1 - Eligibility.docx Supplementary Document Uploaded 2013-11-07 Repair queued
World Trade Center Supptg Stmt A PA_VA application 11 7 13.docx Supporting Statement A Uploaded 2013-11-08 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
209339 Responder Travel Refund Request Form New
209338 Pharmacies Outpatient Prescription Pharmaceuticals Other-Electronic Claims Submission New
209337 Responder Appeals Treatment Other-Letter New
209336 Responder Appeals Certification of Health Conditions Other-Letter New
209335 Responder Appeals to Eligibility Denial Other-Letter New
209334 Responder Eligibility Application Form and Instruction New
ICR Details
0920-1001 201311-0920-009
Historical Active
HHS/CDC 20876
World Trade Center Enrollment & Appeals - Pentagon & Shanksville
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/13/2013
Retrieve Notice of Action (NOA) 11/14/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved
2,685 0 0
831 0 0
0 0 0
Title XXXIII of the Public Health Safety Act establishes the World Trade Center (WTC) Health Program within the Department of Health and Human Services. This program provides medical monitoring and treatment benefits to responders to the September 11, 2001 terrorist attacks in New York City, at the Pentagon, and in Shanksville, PA, and to survivors of the terriorist attacks in New York City.
US Code: 33 USC 3311 Name of Law: Zadroga Act
  
None
0920-AA48 Final or interim final rulemaking 78 FR 18855 03/28/2013
  78 FR 54471 09/04/2013
78 FR 67148 11/08/2013
Yes
  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 2,685 0 0 2,685 0 0
Annual Time Burden (Hours) 831 0 0 831 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new data collection request.
$64,425
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Carol Marsh 404 639-4773 [email protected]
  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.
11/14/2013