Countermeasures Injury Compensation Program (CICP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10 Unreimbursed Medical Expenses Certification (Attach 2)	Form and Instruction	New	Available
Form 9 Unreimbursed Medical Expenses Certification - Estate (Attachment 2)	Form and Instruction	New	Available
Form 8 Lost Employment Income Certification (Attach 3)	Form and Instruction	New	Available
Form 7 Lost Employment Income Certification - Estate (attatchment 3)	Form and Instruction	New	Available
Form 6 Death Benefit Certification of Relationship (Survivor Attach 3)	Form and Instruction	New	Available
Form 5 Compensation Attachment 1	Form and Instruction	New	Available
Form 4 Compensation Attachment 1 for Reps	Form and Instruction	New	Available
Form 3 Compensation Attachment 1 for Estate	Form and Instruction	New	Available
Form 2 Certification of Status for Death Benefit - Standard Calculation (Attachment 1)	Form and Instruction	New	Available
Form 1 Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)	Form and Instruction	New	Available
Form 1 Additional Documentation and Certification	Form	New	Available
Form 1 Authorization for Use or Disclosure of Health Information Form	Form and Instruction	New	Available
Form 1 Request for Benefits Form and Supporting Documentation	Form and Instruction	Modified	Available
2 CICP Authorization Form Instructions.doc	Supplementary Document	Uploaded 2013-08-27	Available
1 Final CICP Request Form Instructions.docx	Supplementary Document	Uploaded 2013-08-27	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2013-08-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Unreimbursed Medical Expenses Certification (Attach 2)
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Unreimbursed Medical Expenses Certification - Estate (Attachment 2)
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Lost Employment Income Certification (Attach 3)
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Lost Employment Income Certification - Estate (attatchment 3)
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Death Benefit Certification of Relationship (Survivor Attach 3)
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Compensation Attachment 1
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Compensation Attachment 1 for Reps
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Compensation Attachment 1 for Estate
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Certification of Status for Death Benefit - Standard Calculation (Attachment 1)
208418	Benefits Package and Supporting Documentation	Form and Instruction	New	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)
208417	Additional Documentation and Certification	Form	New	Additional Documentation and Certification
208416	Authorization for Use or Disclosure of Health Information Form	Form and Instruction	New	Authorization for Use or Disclosure of Health Information Form
194529	Countermeasures Injury Compensation Program Request Package	Form and Instruction	Modified	Request for Benefits Form and Supporting Documentation

ICR Details

OMB Control No: 0915-0334	ICR Reference No: 201308-0915-005
Status: Historical Active	Previous ICR Reference No: 201111-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No: 20201
Title: Countermeasures Injury Compensation Program (CICP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/29/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	09/30/2013
Responses	260	0	2,520
Time Burden (Hours)	1,327	0	12,600
Cost Burden (Dollars)	0	0	0

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Abstract: The Health Resources and Services Administration (HRSA) is requesting approval for the information collection reqirements contained in the 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.

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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

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27241	05/09/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 49530	08/14/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Additional Documentation and Certification	1	Additional Documentation and Certification
Authorization for Use or Disclosure of Health Information Form	1	Authorization for Use or Disclosure of Health Information Form
Benefits Package and Supporting Documentation	1, 2, 3, 4, 5, 6, 7, 8, 9, 10	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2) ,   Certification of Status for Death Benefit - Standard Calculation (Attachment 1) ,   Compensation Attachment 1 for Estate ,   Compensation Attachment 1 for Reps ,   Compensation Attachment 1 ,   Death Benefit Certification of Relationship (Survivor Attach 3) ,   Lost Employment Income Certification - Estate (attatchment 3) ,   Lost Employment Income Certification (Attach 3) ,   Unreimbursed Medical Expenses Certification - Estate (Attachment 2) ,   Unreimbursed Medical Expenses Certification (Attach 2)
Countermeasures Injury Compensation Program Request Package	1	Request for Benefits Form and Supporting Documentation

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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	260	2,520	0	160	-2,420	0
Annual Time Burden (Hours)	1,327	12,600	0	227	-11,500	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The total hours it takes to submit all documentation has increased, due to the amount of time it takes responders to obtain medical records and billing documentation from their healthcare providers. The estimated total number of annual respondents has decreased based on the number of respondents in the past 3 years. The estimated number of respondents in the previous OMB approval was not accurate.

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Annual Cost to Federal Government: $37,127

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

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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: 08/29/2013

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