Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
88.11 Denial Letter and Appeal Notification Eligibility New 47 24 0 Instruction
88.12 World Trade Center Health Condition Certification Request New 32200 16100 0
88.15 Denial Letter and Appeal Notification Treatment New 588 294 0
88.15 Denial Letter and Appeal Notification- Health Conditions New 30 15 0
88.16 Travel Expenses New 10 2 0 Form and Instruction 1
88.3, 88.7 Eligibility and Qualification for WTC Health Program New 290 48 0 Form and Instruction 88.3
88.5 World Trade Center Health Program FDNY Responder Eligibility App New 189 95 0 Instruction
88.5 World Trade Center Health Program Responder App (Other than FDNY) New 2979 1490 0 Form and Instruction 88.5
88.9 World Trade Center Health Program Survivor Eligibility Application New 1560 390 0 Instruction
Outpatient Prescription Pharmaceuticals New 39150 653 0
Total burden requested under this ICR: 77043 19111 0  
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