Countermeasures Injury Compensation Program (CICP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CICP - 1 Countermeasures Injury Compensation Program Request Package	Form	Modified	Available
Justification for non-substantive change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-11-03	Available
CICP Request Form Instructions 8-12-2010.doc	Supplementary Document	Uploaded 2010-08-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194529	Countermeasures Injury Compensation Program Request Package	Form	Modified

ICR Details

OMB Control No: 0915-0334	ICR Reference No: 201111-0915-001
Status: Historical Active	Previous ICR Reference No: 201110-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Countermeasures Injury Compensation Program (CICP)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/16/2011
	Date Received in OIRA: 11/04/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	09/30/2013	09/30/2013
Responses	2,520	0	2,520
Time Burden (Hours)	12,600	0	12,600
Cost Burden (Dollars)	0	0	0

---

Abstract: The Health Resources and Services Administration (HRSA) is requesting approval for the information collection reqirements contained in the Interim Final Rule for the Countermeasures Injury Compensation Program. The Countermeasures Injury Compensation Program is designed to provide compensation to individuals for serious physical injuries or deaths from pandemic, epidemic, or security countermeasures identified in declarations issued by the Secretary pursuant to section 319F-3(b) of the Public Health Service Act.

---

Authorizing Statute(s): PL: Pub.L. 109 - 148 319F3,4 Name of Law: Public Readiness and Emergency Preparedness Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0906-AA83	Final or interim final rulemaking	76 FR 62306	10/07/2011

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Countermeasures Injury Compensation Program Request Package	CICP - 1, 2	CICP Request for Benefits Form ,   Health Information Authorization Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	2,520	2,520	0	0	0	0
Annual Time Burden (Hours)	12,600	12,600	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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:

---

Annual Cost to Federal Government: $43,458

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? No

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

---

Common Form ICR:  No

---

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: 11/04/2011

---