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 Modified 3830 958 17427 Form n/a
Form and Instruction 0920-0891
Designated Representative Form Modified 1300 325 5915 Form and Instruction n/a
Form and Instruction 0920-0891
Designated Representative Revocation Form Modified 15 4 0 Form and Instruction 0920-0891
Form and Instruction 0920-0891
FDNY Responder Eligibility Application Modified 140 70 1701 Form and Instruction n/a
Form n/a
Form and Instruction 0920-0891
Form and Instruction 0920-0891
General Responder Eligibility Application Modified 6215 3108 56557 Form and Instruction n/a
Form and Instruction 0920-0891
Form and Instruction 0920-0891
HIPAA Authorization to Release Information Modified 1300 325 5915 Form and Instruction n/a
Form and Instruction 0920-0891
Member Satisfaction Survey Removed 0 0 0 Form and Instruction 0920-0891
Pentagon / Shanksville Responder Modified 742 371 6752 Form and Instruction n/a
Form and Instruction 0920-0891
Form and Instruction 0920-0891
Petition for the Addition of a Health Condition Modified 35 35 1260 Form and Instruction n/a
Form and Instruction 0920-0891
Survivor Eligibility Application Modified 9240 4620 55440 Form and Instruction n/a
Form and Instruction 0920-0891
Form and Instruction 0920-0891
WTC Health Program General HIPAA Authorization to Third Parties Modified 30 8 0 Form and Instruction 0920-0891
Form and Instruction 0920-0891
Form and Instruction 0920-0891
WTC Health Program HIPAA Authorization for Deceased Individuals Modified 30 8 0 Form and Instruction 0920-0891
Form and Instruction 0920-0891
Form and Instruction 0920-0891
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Removed 0 0 0 Form and Instruction 0920-0891
Youth Research Cohort Registration HIPAA Authorization New 6000 1500 0 Form and Instruction 0920-0891
Youth Research Cohort Registration Portal New 6000 3000 0 Form and Instruction 0920-0891
Total burden requested under this ICR: 34877 14332 150967  
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