OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202408-0920-004 · OMB 0920-0891 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-0891 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction New Repair queued
Form 0920-0891 Designated Representative Revocation Form Form and Instruction Unchanged Missing upstream
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Unchanged Missing upstream
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Unchanged Repair queued
Form 0920-0891 Member Satisfaction Survey Form and Instruction Unchanged Repair queued
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Unchanged Repair queued
HIPAA Authorization to Release Information Form and Instruction Unchanged Repair queued
Designated Representative Form and Instruction Unchanged Repair queued
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Unchanged Repair queued
Survivor Eligibility Application Form and Instruction Unchanged Repair queued
Pentagon / Shanksville Responder Form and Instruction Unchanged Repair queued
General Responder Eligibility Application Form and Instruction Unchanged Repair queued
FDNY Responder Eligibility Application Form and Instruction Unchanged Repair queued
0920-0891_EmergencyReviewRequest_memo.docx Supplementary Document Uploaded 2024-08-22 Missing upstream
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-02-12 Repair queued
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App X Survivor 90 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App W 60 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App V 30 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App U Initial Request for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App ZZ Disenrollment Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App QQ Certification Denial Letter and Appeal.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App AAA Decert Letter Template Admin Error.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App DDD Summary of Forms and Changes.docx Supplementary Document Uploaded 2022-01-06 Repair queued
0920-0891_SSB_Emergency_08212024.docx Supporting Statement B Uploaded 2024-08-22 Repair queued
0920-0891_SSA_Emergency_08212024.docx Supporting Statement A Uploaded 2024-08-22 Repair queued
60d FRN published.pdf Supplementary Document Uploaded 2022-01-06 Repair queued
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-10. NF PA3 Nucala.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-2. PA3 Renewal Form.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-1. General PA3 Form.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document Uploaded 2018-09-20 Repair queued
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App SS Summary of Forms and Changes_100918.docx Supplementary Document Uploaded 2018-10-09 Repair queued
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App PP Disenrollment and Decert Template.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App JJ - Translated 180 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App II - Translated 90 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App HH - Translated 60 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App GG - Translated 30 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App FF - Translated Initial Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App EE IRB Determination.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App DD-1 60-day FRN 05112018.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App X Prior Authorization Form_Transplant.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App W Prior Authorization Form_Dental.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App V Prior Authorization Form_Standard.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App U WTC6 Medication Request.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App T WTC_5 Code or Procedure Request.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App Q 180 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App P 90 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App O 60 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App N 30 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App M Initial Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document Uploaded 2018-09-20 Available
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
270339 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction New
251030 Designated Representative Revocation Form Form and Instruction Unchanged
251023 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Unchanged
251018 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Unchanged
251017 Member Satisfaction Survey Form and Instruction Unchanged
233098 Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Unchanged
233095 HIPAA Authorization to Release Information Form and Instruction Unchanged
218098 Designated Representative Form and Instruction Unchanged
218096 Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Unchanged
214326 Survivor Eligibility Application Form and Instruction Unchanged
214325 Pentagon / Shanksville Responder Form and Instruction Unchanged
214324 General Responder Eligibility Application Form and Instruction Unchanged
214323 FDNY Responder Eligibility Application Form and Instruction Unchanged
ICR Details
0920-0891 202408-0920-004
Received in OIRA 202402-0920-004
HHS/CDC 0920-0891
[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement
Revision of a currently approved collection   No
Emergency 09/11/2024
09/11/2024
  Requested Previously Approved
6 Months From Approved 09/30/2025
29,719 28,977
13,253 12,882
146,417 146,417
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 Emergency ICR is submitted for the 0920-0891 WTCHP package so that data collection activities can begin immediately using a number of forms that permit enrollment of Pentagon/Shanksville, PA responders to the Program in response to an Interim Final Rule (IFR) that will be published September 11, 2024.
On September 11, 2024, CDC plans to publish an Interim Final Rule that expands eligibility for the World Trade Center Health Program (WTCHP) to Pentagon and Shanksville responders. Failure to expedite enrollment processing could significantly harm public health, leaving these eligible individuals waiting for vital healthcare services. Emergency processing is imperative to prevent enrollment delays and potential adverse health outcomes. Therefore, expedited processing is not only necessary but crucial for ensuring timely access to health benefits for these responders. Submission of a full/standard Revision ICR will follow.
PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  
None
0920-AA86 Final or interim final rulemaking 89 FR 73592 09/11/2024
No
13
IC Title Form No. Form Name
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic n/a Clinic Selection Postcard
Designated Representative n/a Designated Representative Form
Designated Representative Revocation Form 0920-0891 Designated Representative Revocation Form
FDNY Responder Eligibility Application n/a, n/a FDNY Responder Eligibility Application ,   Screen shots of Web interface for electronic reporting option
General Responder Eligibility Application n/a, n/a, n/a General Responder (other than FDNY) Eligibility Application [English] ,   General Responder (other than FDNY) Eligibility Application [Spanish] ,   General Responder (other than FDNY) Eligibility Application [Polish]
HIPAA Authorization to Release Information n/a HIPAA Authorization Form to Release Information
Member Satisfaction Survey 0920-0891 Member Satisfaction Survey
Pentagon / Shanksville Responder n/a Pentagon / Shanksville Responder Eligibility Application
Petition for the Addition of a Health Condition (previously approved under 0920-0929) n/a Petition for the addition of health conditions
Survivor Eligibility Application n/a, n/a, n/a, n/a Eligibility Application for Survivors [English] ,   Eligibility Application for Survivors [Spanish] ,   Eligibility Application for Survivors [Polish] ,   Eligibility Application for Survivors [Chinese]
WTC Health Program General HIPAA Authorization to Third Parties 0920-0891, 0920-0891 WTC Health Program HIPAA Authorization - Third Parties ,   General HIPAA Authorization for Disclosures to Third Parties
WTC Health Program HIPAA Authorization for Deceased Individuals 0920-0891, 0920-0891 WTC Health Program HIPAA Authorization - Deceased Individuals ,   HIPAA Authorization for Disclosures Regarding Deceased Individuals
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment 0920-0891 WTCHP - Application for Enrollment: Pentagon/Shanksville Responder
  Total Request 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 29,719 28,977 0 742 0 0
Annual Time Burden (Hours) 13,253 12,882 0 371 0 0
Annual Cost Burden (Dollars) 146,417 146,417 0 0 0 0
Yes
Changing Regulations
No
Emergency Revision of 0920-0891 package results in increase of 371 burden hours to permit enrollment of Pentagon/Shanksville, PA responders to the WTCHP.
$323,763
No
    Yes
    Yes
No
No
No
No
Jeffrey Zirger 404 639-7118 [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.
09/11/2024