Youth Research Cohort Registration HIPAA Authorization

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

Documents and Forms

Document Name Document Type
Form 0920-0891 Youth Research Cohort Registration HIPAA Authorization Form and Instruction
0920-0891 WTCHP Youth Research Cohort HIPAA Authorization Form_10F App Q1-YRC HIPAA Authorization Form 2025.pdf Form and Instruction
0920-0891 WTCHP Youth Research Cohort HIPAA Authorization Form_10F App Q1-YRC HIPAA Authorization Form 2025.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Youth Research Cohort Registration HIPAA Authorization	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	0920-0891	WTCHP Youth Research Cohort HIPAA Authorization Form_10FEB2025	App Q1-YRC HIPAA Authorization Form 2025.pdf	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies and EEOICPA Progr09-20-0147 Records and WTC Health Program Records, HHS/CDC/NIOSH	FR Citation: 76 FR 34706

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	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.