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OMB Control No: 0920-0891	ICR Reference No: 201106-0920-016
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Emergency	Approval Requested By: 06/28/2011
OIRA Conclusion Action: Preapproved	Conclusion Date: 06/27/2011
	Date Received in OIRA: 06/27/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	6 Months From Approved
Responses	77,043	0	0
Time Burden (Hours)	19,111	0	0
Cost Burden (Dollars)	0	0	0

Abstract: The proposed collection will collect enrollment and appeals data as required by the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Zadroga Act which was passed on December 22, 2010 establishes a federal program to support health monitoring and treatment for emergency responders; recovery and cleanup workers; and residents, building occupants, and area workers in New York City who were directly impacted and adversely affected by the terrorist attacks of September 11, 2001. All responders to the New York City attack who will be newly seeking medical monitoring and treatment and survivors of the attack who were not covered by the Medical Monitoring and Treatment Program (MMTP) prior to January 2, 2011, may apply to obtain coverage under the new WTC Health Program. In order to begin the determination eligibility process, an enrollment form must be completed. There are three separate enrollment forms for each population of responders (FDNY responders, non-FDNY responders, and Survivors). The enrollment form will collect general contact information as well as information regarding the WTC disaster area experience. In order to reduce the burden on the respondents and survivors, the WTC Health program will make the form available to be downloaded from the internet or obtained in hard copy and submitted by mail.

Emergency Justfication: This is an emergency ICR request that is tied to Rulemaking, which can be found under (42 CFR 88)

Authorizing Statute(s): PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act

Citations for New Statutory Requirements: PL: Pub.L. 847 - 42 88 Name of Law: CFR

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA44	Final or interim final rulemaking

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Request	Change Due to New Statute
Annual Number of Responses	77,043	77,043
Annual Time Burden (Hours)	19,111	19,111
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR emergency submission provided under Public Law 847-42 -88 Zadroga Act

Annual Cost to Federal Government: $95,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Daniel Holcomb 770 488-4472 dwh6@cdc.gov

View ICR - OIRA Conclusion