Survivor Eligibility Application

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

OMB: 0920-0891

IC ID: 214326

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Information Collection (IC) Details

View Information Collection (IC)

Survivor Eligibility Application
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH  76 FR 34706

9,240 0
   
Individuals or Households
 
   0 %

  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 9,240 0 0 0 9,240 0
Annual IC Time Burden (Hours) 4,620 0 0 0 4,620 0
Annual IC Cost Burden (Dollars) 55,440 0 0 0 55,440 0

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.

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