Countermeasures Injury Compensation Program Request Package

Countermeasures Injury Compensation Program (CICP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0334 can be found here:

Documents and Forms

Document Name Document Type
Form CICP - 1 Countermeasures Injury Compensation Program Request Package Form
CICP - 1 CICP Request for Benefits Form (Attachment D) CICP Request Forms 8-12-2010.docx Form
2 Health Information Authorization Form HIPAA Health Info Disclosure Form-FINAL[1].doc Form
CICP Request Form Instructions 8-12-2010.doc CICP Request for Benefits Instructions IC Document

Information Collection (IC) Details

IC Title:	Countermeasures Injury Compensation Program Request Package	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CICP - 1	CICP Request for Benefits Form	(Attachment D) CICP Request Forms 8-12-2010.docx		Yes	No	Fillable Printable
Form	2	Health Information Authorization Form	HIPAA Health Info Disclosure Form-FINAL[1].doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,520	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,520	2,520
Annual IC Time Burden (Hours)	12,600	12,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CICP Request for Benefits Instructions	CICP Request Form Instructions 8-12-2010.doc	08/12/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.