Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Unchanged 3830 958 17427 Form n/a
Designated Representative Unchanged 1300 325 5915 Form and Instruction n/a
Designated Representative Revocation Form Unchanged 15 4 0 Form and Instruction 0920-0891
FDNY Responder Eligibility Application Unchanged 140 70 1701 Form and Instruction n/a
Form n/a
General Responder Eligibility Application Unchanged 6215 3108 56557 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
HIPAA Authorization to Release Information Unchanged 1300 325 5915 Form and Instruction n/a
Member Satisfaction Survey Unchanged 6600 3300 0 Form and Instruction 0920-0891
Pentagon / Shanksville Responder Unchanged 242 121 2202 Form and Instruction n/a
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Unchanged 35 35 1260 Form and Instruction n/a
Survivor Eligibility Application Unchanged 9240 4620 55440 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
WTC Health Program General HIPAA Authorization to Third Parties Unchanged 30 8 0 Form and Instruction 0920-0891
Form and Instruction 0920-0891
WTC Health Program HIPAA Authorization for Deceased Individuals Unchanged 30 8 0 Form and Instruction 0920-0891
Form and Instruction 0920-0891
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment New 742 371 0 Form and Instruction 0920-0891
Total burden requested under this ICR: 29719 13253 146417  
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