Survivor Eligibility Application

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

OMB: 0920-0891

IC ID: 214326

Documents and Forms

Document Name Document Type
Survivor Eligibility Application Form and Instruction
Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx Form and Instruction
Eligibility Application for Survivors [English] App H Eligibility_Form_for_Survivors.docx Form and Instruction
0920-0891 WTCHP Survivor Application_Eng_10FEB2025 App F-WTCHP Survivor App for Enrollment_Eng.pdf Form and Instruction
0920-0891 WTCHP Survivor Application_Eng_10FEB2025 App F-WTCHP Survivor App for Enrollment_Eng.pdf Form and Instruction
0920-0891 WTCHP Survivor Application_Eng 19FEB2025 App F-WTCHP Survivor Application English_FINAL.pdf Form and Instruction
0920-0891 WTCHP Survivor Application_Eng 19FEB2025 App F-WTCHP Survivor Application English_FINAL.pdf Form and Instruction
App G-WTCHP Survivor App for Enrollment_Span.pdf WTCHP Survivor Application_Span_10FEB2025 IC Document
App G-WTCHP Survivor App for Enrollment_Span.pdf WTCHP Survivor Application_Span_10FEB2025 IC Document
App H-WTCHP Survivor Application Polish.pdf WTCHP Survivor Application_Polish_10FEB2025 IC Document
App H-WTCHP Survivor Application Polish.pdf WTCHP Survivor Application_Polish_10FEB2025 IC Document
App I-WTCHP Survivor Application Chinese.pdf WTCHP Survivor Application_Chinese_10FEB2025 IC Document
App I-WTCHP Survivor Application Chinese.pdf WTCHP Survivor Application_Chinese_10FEB2025 IC Document
App G-WTCHP Survivor Application Spanish_FINAL.pdf WTCHP Survivor Application_Span 19FEB2025 IC Document
App G-WTCHP Survivor Application Spanish_FINAL.pdf WTCHP Survivor Application_Span 19FEB2025 IC Document
App H-WTCHP Survivor Application Polish_FINAL.pdf WTCHP Survivor Application_Polish 19FEB2025 IC Document
App H-WTCHP Survivor Application Polish_FINAL.pdf WTCHP Survivor Application_Polish 19FEB2025 IC Document
App I-WTCHP Survivor Application Chinese_FINAL.pdf WTCHP Survivor Application_Chinese 19FEB2025 IC Document
App I-WTCHP Survivor Application Chinese_FINAL.pdf WTCHP Survivor Application_Chinese 19FEB2025 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survivor Eligibility Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	Eligibility Application for Survivors [English]	App H Eligibility_Form_for_Survivors.docx		No		Paper Only
Form and Instruction	0920-0891	WTCHP Survivor Application_Eng_10FEB2025	App F-WTCHP Survivor App for Enrollment_Eng.pdf	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	WTCHP Survivor Application_Eng 19FEB2025	App F-WTCHP Survivor Application English_FINAL.pdf	N/A	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: 9,240	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,240	9,240
Annual IC Time Burden (Hours)	4,620	4,620
Annual IC Cost Burden (Dollars)	55,440	55,440

Documents for IC

Title	Document	Date Uploaded
WTCHP Survivor Application_Span_10FEB2025	App G-WTCHP Survivor App for Enrollment_Span.pdf	02/10/2025
WTCHP Survivor Application_Polish_10FEB2025	App H-WTCHP Survivor Application Polish.pdf	02/10/2025
WTCHP Survivor Application_Chinese_10FEB2025	App I-WTCHP Survivor Application Chinese.pdf	02/10/2025
WTCHP Survivor Application_Span 19FEB2025	App G-WTCHP Survivor Application Spanish_FINAL.pdf	02/24/2025
WTCHP Survivor Application_Polish 19FEB2025	App H-WTCHP Survivor Application Polish_FINAL.pdf	02/24/2025
WTCHP Survivor Application_Chinese 19FEB2025	App I-WTCHP Survivor Application Chinese_FINAL.pdf	02/24/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.