Countermeasures Injury Compensation Program Request Package

Countermeasures Injury Compensation Program (CICP)

OMB: 0915-0334

IC ID: 194529

Information Collection (IC) Details

View Information Collection (IC)

Countermeasures Injury Compensation Program Request Package
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

 

2,520 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,520 0 0 0 0 2,520
Annual IC Time Burden (Hours) 12,600 0 0 0 0 12,600
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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