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⚠️ Notice: This information collection may be referencing outdated material.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 1 Countermeasures Injury Compensation Program Request Package Form and Instruction
1 Request for Benefits Form and Supporting Documentation 1 Final CICP Request Form (with color).docx Form and Instruction
1 Final CICP Request Form Instructions.docx Instructions - Request for Benefits Form and Supporting Documentation 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 and Instruction	1	Request for Benefits Form and Supporting Documentation	1 Final CICP Request Form (with color).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: The Countermeasures Injury Compensation Program, HHS/HRSA/HSB	FR Citation: 76 FR 28991

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	-2,420	2,520
Annual IC Time Burden (Hours)	1,100	-11,500	12,600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Instructions - Request for Benefits Form and Supporting Documentation	1 Final CICP Request Form Instructions.docx	08/27/2013

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