OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 201412-0920-012 · OMB 0920-0891 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Pharmacy - Outpatient Prescription Pharmaceuticals Form New Repair queued
Designated Rep Form Form New Available
WTC-3 Form New Repair queued
Clinic Selection Postcard Form New Repair queued
Responder Medical Travel Refund Request Form New Available
Responder Denial and Appeal - Treatment Form New Available
Responder Denial and Appeal - Health Conditions Form New Repair queued
Responder Denial and Appeal - Eligibility Form New Available
Survivor Eligibility Form New Repair queued
Pentagon / Shanksville Responder Form New Available
General Responder Eligibility Application Form New Available
FDNY Responder Eligibility Application Form New Repair queued
Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction Removed Available
Form 12 Currently Identified Responders and Currently Identified Survivors Form Removed Available
Form 2 88.12 World Trade Center Health Condition Certification Request Form and Instruction Removed Available
Form 88.5 88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction Removed Available
Appendix P WTC_6_Final.pdf Supplementary Document Uploaded 2015-09-04 Available
Appendix O WTC_5_Final.pdf Supplementary Document Uploaded 2015-09-04 Available
Appendix T Pharmacy Prior Authorization_Final.pdf Supplementary Document Uploaded 2015-09-04 Available
Appendix S PA3 Transplant_Final.pdf Supplementary Document Uploaded 2015-09-04 Repair queued
Appendix R PA3_Dental_Final.pdf Supplementary Document Uploaded 2015-09-04 Available
Appendix Q PA3 Standard_Final.pdf Supplementary Document Uploaded 2015-09-04 Available
Appendix Z HSRB.pdf Supplementary Document Uploaded 2015-09-04 Available
Appendix W Treatment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2015-09-04 Repair queued
Appendix V Enrollment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2015-09-04 Available
Appendix U Enrollment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2015-09-04 Available
Appendix Y Response to Public Comments.docx Supplementary Document Uploaded 2015-09-04 Repair queued
Appendix J Public comments.docx Supplementary Document Uploaded 2014-12-30 Available
Appendix K IRB.pdf Supplementary Document Uploaded 2014-12-18 Available
Appendix B 60dy FRN.pdf Supplementary Document Uploaded 2014-12-18 Available
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Repair queued
Supporting Statement B.docx Supporting Statement B Uploaded 2015-09-03 Available
Supptg Stmt A.doc Supporting Statement A Uploaded 2015-09-03 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
218099 Pharmacy - Outpatient Prescription Pharmaceuticals Form New
218098 Designated Rep Form Form New
218097 WTC-3 Form New
218096 Clinic Selection Postcard Form New
214337 Responder Medical Travel Refund Request Form New
214336 Responder Denial and Appeal - Treatment Form New
214335 Responder Denial and Appeal - Health Conditions Form New
214327 Responder Denial and Appeal - Eligibility Form New
214326 Survivor Eligibility Form New
214325 Pentagon / Shanksville Responder Form New
214324 General Responder Eligibility Application Form New
214323 FDNY Responder Eligibility Application Form New
200509 ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction Removed
200508 Currently Identified Responders and Currently Identified Survivors Form Removed
198312 88.16 Travel Expenses Removed
198311 Outpatient Prescription Pharmaceuticals Removed
198310 88.15 Denial Letter and Appeal Notification- Health Conditions Removed
198309 88.15 Denial Letter and Appeal Notification Treatment Removed
198308 88.12 World Trade Center Health Condition Certification Request Form and Instruction Removed
198307 88.11 Denial Letter and Appeal Notification Eligibility Instruction Removed
198306 88.9 World Trade Center Health Program Survivor Eligibility Application Instruction Removed
198305 88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction Removed
198304 88.5 World Trade Center Health Program FDNY Responder Eligibility App Instruction Removed
ICR Details
0920-0891 201412-0920-012
Historical Active 201406-0920-001
HHS/CDC 19888
World Trade Center Health Program Enrollment, Appeals & Reimbursement
Revision of a currently approved collection   No
Regular
Approved with change 09/14/2015
Retrieve Notice of Action (NOA) 12/30/2014
  Inventory as of this Action Requested Previously Approved
09/30/2018 36 Months From Approved 09/30/2015
66,276 0 77,243
13,594 0 19,161
0 0 0
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.
PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  
None
Not associated with rulemaking
  79 FR 39399 07/10/2014
79 FR 77007 12/23/2014
Yes
12
IC Title Form No. Form Name
Clinic Selection Postcard none Clinic Selection Postcard
WTC-3 none Physician Request for Certification
Designated Rep Form none Designate a Representative
Pharmacy - Outpatient Prescription Pharmaceuticals none Pharmacy
Currently Identified Responders and Currently Identified Survivors 12 Eligibility and Qualification for WTC Health Program
88.5 World Trade Center Health Program FDNY Responder Eligibility App none FDNY Responder Eligibility
88.5 World Trade Center Health Program Responder App (Other than FDNY) 88.5, none World Trade Center Health Program Responder App (Other than FDNY) ,   Eligibility Other than FDNY
88.9 World Trade Center Health Program Survivor Eligibility Application none Survivors
88.11 Denial Letter and Appeal Notification Eligibility
88.12 World Trade Center Health Condition Certification Request 2 New Determinations for WTC Certification
88.15 Denial Letter and Appeal Notification Treatment
88.15 Denial Letter and Appeal Notification- Health Conditions
Outpatient Prescription Pharmaceuticals
88.16 Travel Expenses
ACH Vendor/Miscellaneous Payment Enrollment Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form
Responder Denial and Appeal - Health Conditions none Denial and Appeal Letters
Responder Denial and Appeal - Treatment none Denial Letters and Appeal Notification
Responder Medical Travel Refund Request none Travel Refund Request
FDNY Responder Eligibility Application none FDNY
General Responder Eligibility Application none Non FDNY Application
Pentagon / Shanksville Responder none Pentagon/Shanksville
Survivor Eligibility none Survivor Eligibility
Responder Denial and Appeal - Eligibility None Denial Letter and Appeal Notification
  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 66,276 77,243 0 -10,967 0 0
Annual Time Burden (Hours) 13,594 19,161 0 -5,567 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
This revision request incorporates changes to forms, and the consolidation of two ICRs. There is a reduction in burden hours and respondents.
$1,080,300
No
Yes
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.
12/30/2014