Information Collection

Responder Denial and Appeal - Eligibility

IC 214327 under ICR 201703-0920-004 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Document Name Document Type
Responder Denial and Appeal - Eligibility Form and Instruction
Enrollment Denial Letter and Appeal Notification App Z Enrollment Denial Letter and Appeal Notification.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Responder Denial and Appeal - Eligibility	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Enrollment Denial Letter and Appeal Notification	App Z Enrollment Denial Letter and Appeal Notification.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH	FR Citation: 76 FR 34706

Number of Respondents: 45	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	45	0	45
Annual IC Time Burden (Hours)	23	0	23
Annual IC Cost Burden (Dollars)	405	405	0

Documents for IC

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.