Information Collection

Countermeasures Injury Compensation Program Request Package

IC 194529 under ICR 201111-0915-005 · OMB 0915-0334.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Countermeasures Injury Compensation Program Request Package	Form
2 Health Information Authorization Form HIPAA Health Info Disclosure Form-FINAL[1].doc	Form
1 CICP Request for Benefits Form CICP Request Forms.docx	Form
CICP Request Form Instructions.doc CICP Request Form Instructions 11.22.2011	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Health Information Authorization Form	HIPAA Health Info Disclosure Form-FINAL[1].doc		Yes	No	Fillable Printable
Form	1	CICP Request for Benefits Form	CICP Request Forms.docx		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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
CICP Request Form Instructions 11.22.2011	CICP Request Form Instructions.doc	11/22/2011

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