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Pentagon / Shanksville Responder
[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement
OMB: 0920-0891
IC ID: 214325
OMB.report
HHS/CDC
OMB 0920-0891
ICR 202502-0920-001
IC 214325
( )
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
View Information Collection (IC)
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
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:
742
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
50 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
742
0
500
0
242
0
Annual IC Time Burden (Hours)
371
0
250
0
121
0
Annual IC Cost Burden (Dollars)
6,752
0
4,550
0
2,202
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.