[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Document Name	Status
Form 0920-0891 World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction	New
Form 0920-0891 Designated Representative Revocation Form Form and Instruction	Unchanged
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction	Unchanged
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction	Unchanged
Form 0920-0891 Member Satisfaction Survey Form and Instruction	Unchanged
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction	Unchanged
HIPAA Authorization to Release Information Form and Instruction	Unchanged
Designated Representative Form and Instruction	Unchanged
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form	Unchanged
Survivor Eligibility Application Form and Instruction	Unchanged
Pentagon / Shanksville Responder Form and Instruction	Unchanged
General Responder Eligibility Application Form and Instruction	Unchanged
FDNY Responder Eligibility Application Form and Instruction	Unchanged
0920-0891_EmergencyReviewRequest_memo.docx Supplementary Document	2024-08-22
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change	2024-02-12
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document	2022-01-06
App X Survivor 90 Day Suspend Letter.docx Supplementary Document	2022-01-06
App W 60 Day Suspend Letter.docx Supplementary Document	2022-01-06
App V 30 Day Suspend Letter.docx Supplementary Document	2022-01-06
App U Initial Request for Additional Information.docx Supplementary Document	2022-01-06
App ZZ Disenrollment Letter.docx Supplementary Document	2022-01-06
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document	2022-01-06
App QQ Certification Denial Letter and Appeal.docx Supplementary Document	2022-01-06
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document	2022-01-06
App AAA Decert Letter Template Admin Error.docx Supplementary Document	2022-01-06
App DDD Summary of Forms and Changes.docx Supplementary Document	2022-01-06
0920-0891_SSB_Emergency_08212024.docx Supporting Statement B	2024-08-22
0920-0891_SSA_Emergency_08212024.docx Supporting Statement A	2024-08-22
60d FRN published.pdf Supplementary Document	2022-01-06
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document	2018-10-09
App Y-10. NF PA3 Nucala.pdf Supplementary Document	2018-10-09
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document	2018-10-09
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document	2018-10-09
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document	2018-10-09
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document	2018-10-09
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document	2018-10-09
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document	2018-10-09
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document	2018-10-09
App Y-2. PA3 Renewal Form.pdf Supplementary Document	2018-10-09
App Y-1. General PA3 Form.pdf Supplementary Document	2018-10-09
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document	2018-09-20
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document	2018-09-20
App SS Summary of Forms and Changes_100918.docx Supplementary Document	2018-10-09
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document	2018-09-20
App PP Disenrollment and Decert Template.docx Supplementary Document	2018-09-20
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document	2018-09-20
App JJ - Translated 180 Day Request for Information.docx Supplementary Document	2018-09-20
App II - Translated 90 Day Request for Information.docx Supplementary Document	2018-09-20
App HH - Translated 60 Day Request for Information.docx Supplementary Document	2018-09-20
App GG - Translated 30 Day Request for Information.docx Supplementary Document	2018-09-20
App FF - Translated Initial Request for Information.docx Supplementary Document	2018-09-20
App EE IRB Determination.pdf Supplementary Document	2018-09-20
App DD-1 60-day FRN 05112018.pdf Supplementary Document	2018-09-20
App X Prior Authorization Form_Transplant.pdf Supplementary Document	2018-09-20
App W Prior Authorization Form_Dental.pdf Supplementary Document	2018-09-20
App V Prior Authorization Form_Standard.pdf Supplementary Document	2018-09-20
App U WTC6 Medication Request.pdf Supplementary Document	2018-09-20
App T WTC_5 Code or Procedure Request.pdf Supplementary Document	2018-09-20
App Q 180 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App P 90 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App O 60 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App N 30 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App M Initial Letter Requesting Information.docx Supplementary Document	2018-09-20
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document	2018-09-20
Appendix A Legislation.docx Supplementary Document	2014-12-18

IC Document Collections

IC ID	Document Title	Status
270339	World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment Form and Instruction	New
251030	Designated Representative Revocation Form Form and Instruction	Unchanged
251023	WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction	Unchanged
251018	WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction	Unchanged
251017	Member Satisfaction Survey Form and Instruction	Unchanged
233098	Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction	Unchanged
233095	HIPAA Authorization to Release Information Form and Instruction	Unchanged
218098	Designated Representative Form and Instruction	Unchanged
218096	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form	Unchanged
214326	Survivor Eligibility Application Form and Instruction	Unchanged
214325	Pentagon / Shanksville Responder Form and Instruction	Unchanged
214324	General Responder Eligibility Application Form and Instruction	Unchanged
214323	FDNY Responder Eligibility Application Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 202408-0920-004
Status: Received in OIRA	Previous ICR Reference No: 202402-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0891
Title: [NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/11/2024
Date Submitted to OIRA: 09/11/2024

	Requested	Previously Approved
Expiration Date	6 Months From Approved	09/30/2025
Responses	29,719	28,977
Time Burden (Hours)	13,253	12,882
Cost Burden (Dollars)	146,417	146,417

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Abstract: The WTC Health Program is a limited healthcare program established by the James Zadroga 9/11 Health and Compensation Act of 2010. The goal of the Program is to provide monitoring and treatment to responders of the 9/11 terrorist attacks at the World Trade Center, Pentagon, and Shanksville, PA, as well as survivors in the New York City Area. The data collected contained within this OMB package are intended solely for determining eligibility and treatment. This Emergency ICR is submitted for the 0920-0891 WTCHP package so that data collection activities can begin immediately using a number of forms that permit enrollment of Pentagon/Shanksville, PA responders to the Program in response to an Interim Final Rule (IFR) that will be published September 11, 2024.

Emergency Justfication: On September 11, 2024, CDC plans to publish an Interim Final Rule that expands eligibility for the World Trade Center Health Program (WTCHP) to Pentagon and Shanksville responders. Failure to expedite enrollment processing could significantly harm public health, leaving these eligible individuals waiting for vital healthcare services. Emergency processing is imperative to prevent enrollment delays and potential adverse health outcomes. Therefore, expedited processing is not only necessary but crucial for ensuring timely access to health benefits for these responders. Submission of a full/standard Revision ICR will follow.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0920-AA86	Final or interim final rulemaking	89 FR 73592	09/11/2024

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 13

IC Title	Form No.	Form Name
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	n/a	Clinic Selection Postcard
Designated Representative	n/a	Designated Representative Form
Designated Representative Revocation Form	0920-0891	Designated Representative Revocation Form
FDNY Responder Eligibility Application	n/a, n/a	FDNY Responder Eligibility Application ,   Screen shots of Web interface for electronic reporting option
General Responder Eligibility Application	n/a, n/a, n/a	General Responder (other than FDNY) Eligibility Application [English] ,   General Responder (other than FDNY) Eligibility Application [Spanish] ,   General Responder (other than FDNY) Eligibility Application [Polish]
HIPAA Authorization to Release Information	n/a	HIPAA Authorization Form to Release Information
Member Satisfaction Survey	0920-0891	Member Satisfaction Survey
Pentagon / Shanksville Responder	n/a	Pentagon / Shanksville Responder Eligibility Application
Petition for the Addition of a Health Condition (previously approved under 0920-0929)	n/a	Petition for the addition of health conditions
Survivor Eligibility Application	n/a, n/a, n/a, n/a	Eligibility Application for Survivors [English] ,   Eligibility Application for Survivors [Spanish] ,   Eligibility Application for Survivors [Polish] ,   Eligibility Application for Survivors [Chinese]
WTC Health Program General HIPAA Authorization to Third Parties	0920-0891, 0920-0891	WTC Health Program HIPAA Authorization - Third Parties ,   General HIPAA Authorization for Disclosures to Third Parties
WTC Health Program HIPAA Authorization for Deceased Individuals	0920-0891, 0920-0891	WTC Health Program HIPAA Authorization - Deceased Individuals ,   HIPAA Authorization for Disclosures Regarding Deceased Individuals
World Trade Center Health Program Pentagon/Shanksville Responder Application for Enrollment	0920-0891	WTCHP - Application for Enrollment: Pentagon/Shanksville Responder

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	29,719	28,977	0	742	0	0
Annual Time Burden (Hours)	13,253	12,882	0	371	0	0
Annual Cost Burden (Dollars)	146,417	146,417	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: Emergency Revision of 0920-0891 package results in increase of 371 burden hours to permit enrollment of Pentagon/Shanksville, PA responders to the WTCHP.

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Annual Cost to Federal Government: $323,763

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/11/2024

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