[NIOSH] EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

ICR 202211-0920-005

OMB: 0920-0639

Federal Form Document

Forms and Documents

Document Name	Status
Form A: Special Exposure Cohort Petition 42 CFR 83.9 Form and Instruction	Unchanged
Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction	Unchanged
Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 Form and Instruction	Unchanged
Attachment F HSRB NR Determination 2022_12_01.pdf Supplementary Document	2022-12-06
Attachment B 60-day FRN 2022_08_03.pdf Supplementary Document	2022-12-06
Attachment A EEOICPA.pdf Supplementary Document	2019-09-23
SSB_0639_102622.docx Supporting Statement B	2022-12-06
SSA_0639_rev.120122.docx Supporting Statement A	2022-12-06

IC Document Collections

IC ID	Document Title	Status
7107	Form A: Special Exposure Cohort Petition 42 CFR 83.9 Form and Instruction	Unchanged
180186	Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction	Unchanged
180185	Petitioner Appealing Final Decision under 42 CFR 83.18 Other-Example Request for Review	Unchanged
180184	Petitioner Submission Format other than Form B 42 CFR 83.9 Instruction	Unchanged
180183	Form B: Special Exposure Cohort Petition 42 CFR Part 83.9 Form and Instruction	Unchanged