Information Collection

Countermeasures Injury Compensation Program Request Package

IC 194529 under ICR 201308-0915-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.