Pentagon / Shanksville Responder

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

Documents and Forms

Document Name Document Type
Pentagon / Shanksville Responder Form and Instruction
Pentagon / Shanksville Responder Eligibility Application App G Pentagon-Shanksville Application.docx Form and Instruction
Pentagon / Shanksville Responder Eligibility Application App G Pentagon-Shanksville Application.docx Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application_10FEB2025 App E-WTCHP Pentagon Shanksville App for Enrollment.pdf Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application_10FEB2025 App E-WTCHP Pentagon Shanksville App for Enrollment.pdf Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application 19FEB2025 App E-WTCHP Pentagon Shanksville Enrollment_FINAL.pdf Form and Instruction
0920-0891 WTCHP Pentagon_Shanksville Application 19FEB2025 App E-WTCHP Pentagon Shanksville Enrollment_FINAL.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Pentagon / Shanksville Responder	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	Pentagon / Shanksville Responder Eligibility Application	App G Pentagon-Shanksville Application.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	WTCHP Pentagon_Shanksville Application_10FEB2025	App E-WTCHP Pentagon Shanksville App for Enrollment.pdf	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	WTCHP Pentagon_Shanksville Application 19FEB2025	App E-WTCHP Pentagon Shanksville Enrollment_FINAL.pdf	N/A	Yes	Yes	Fillable Fileable

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: 742	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	742	500	242
Annual IC Time Burden (Hours)	371	250	121
Annual IC Cost Burden (Dollars)	6,752	4,550	2,202

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.