Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
88.11 Denial Letter and Appeal Notification Eligibility Removed 0 0 0 Instruction
88.12 World Trade Center Health Condition Certification Request Removed 0 0 0 Form and Instruction 2
88.15 Denial Letter and Appeal Notification Treatment Removed 0 0 0
88.15 Denial Letter and Appeal Notification- Health Conditions Removed 0 0 0
88.16 Travel Expenses Removed 0 0 0
88.5 World Trade Center Health Program FDNY Responder Eligibility App Removed 0 0 0 Instruction
Form none
88.5 World Trade Center Health Program Responder App (Other than FDNY) Removed 0 0 0 Form and Instruction 88.5
Form and Instruction none
88.9 World Trade Center Health Program Survivor Eligibility Application Removed 0 0 0 Instruction
Form and Instruction none
ACH Vendor/Miscellaneous Payment Enrollment Form Removed 0 0 0 Form and Instruction 11
Clinic Selection Postcard New 2475 619 0 Form none
Currently Identified Responders and Currently Identified Survivors Removed 0 0 0 Form 12
Designated Rep Form New 10 3 0 Form none
FDNY Responder Eligibility Application New 45 23 0 Form none
General Responder Eligibility Application New 2475 1238 0 Form none
Outpatient Prescription Pharmaceuticals Removed 0 0 0
Pentagon / Shanksville Responder New 630 315 0 Form none
Pharmacy - Outpatient Prescription Pharmaceuticals New 39150 653 0 Form none
Responder Denial and Appeal - Eligibility New 45 23 0 Form None
Responder Denial and Appeal - Health Conditions New 60 30 0 Form none
Responder Denial and Appeal - Treatment New 26 13 0 Form none
Responder Medical Travel Refund Request New 10 2 0 Form none
Survivor Eligibility New 1350 675 0 Form none
WTC-3 New 20000 10000 0 Form none
Total burden requested under this ICR: 66276 13594 0  
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