World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Document Name	Status
Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction	Unchanged
Form 12 Currently Identified Responders and Currently Identified Survivors Form	Unchanged
Form 2 88.12 World Trade Center Health Condition Certification Request Form and Instruction	Unchanged
Form 88.5 88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction	Modified
Request for Nonsubstantive Change 0920-0891 - Copy.docx Justification for No Material/Nonsubstantive Change	2014-06-03

IC Document Collections

IC ID	Document Title	Status
200509	ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction	Unchanged
200508	Currently Identified Responders and Currently Identified Survivors Form	Unchanged
198312	88.16 Travel Expenses	Unchanged
198311	Outpatient Prescription Pharmaceuticals	Unchanged
198310	88.15 Denial Letter and Appeal Notification- Health Conditions	Unchanged
198309	88.15 Denial Letter and Appeal Notification Treatment	Unchanged
198308	88.12 World Trade Center Health Condition Certification Request Form and Instruction	Unchanged
198307	88.11 Denial Letter and Appeal Notification Eligibility Instruction	Unchanged
198306	88.9 World Trade Center Health Program Survivor Eligibility Application Instruction	Modified
198305	88.5 World Trade Center Health Program Responder App (Other than FDNY) Form and Instruction	Modified
198304	88.5 World Trade Center Health Program FDNY Responder Eligibility App Instruction	Modified

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 201406-0920-001
Status: Historical Active	Previous ICR Reference No: 201307-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 19888
Title: World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/11/2014
	Date Received in OIRA: 06/05/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	12/31/2014	12/31/2014
Responses	77,243	0	77,243
Time Burden (Hours)	19,161	0	19,161
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request to make minor changes to three forms in order to improve clarity for the applicant and to accurately reflect the Act.

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Authorizing Statute(s): PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA44	Final or interim final rulemaking	76 FR 38913	07/01/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

IC Title	Form No.	Form Name
Outpatient Prescription Pharmaceuticals
88.16 Travel Expenses
Currently Identified Responders and Currently Identified Survivors	12	Eligibility and Qualification for WTC Health Program
ACH Vendor/Miscellaneous Payment Enrollment Form	11	ACH Vendor/Miscellaneous Payment Enrollment Form
88.11 Denial Letter and Appeal Notification Eligibility
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
88.12 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

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ICR Summary of Burden

	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	77,243	77,243	0	0	0	0
Annual Time Burden (Hours)	19,161	19,161	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $95,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/05/2014

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