Benefits Package and Supporting Documentation

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⚠️ Notice: This information collection may be referencing outdated material.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 4 Benefits Package and Supporting Documentation Form and Instruction
Compensation Attachment 1.docx Instruction
Compensation Attachment 1 for Reps.docx Instruction
Compensation Attachment 1 for Estate.docx Instruction
1 Certification of Status for Death Benefit - Alternative Certification of Status for Death Benefit - Alternative Calculation.docx Form and Instruction
2 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation.docx Form and Instruction
3 Death Benefit Certification of Relationship Survivor.doc Death Benefit Certification of Relationship Survivor.docx Form and Instruction
4 Lost Employment Income Certification - Estate.docx Lost Employment Income Certification - Estate.docx Form and Instruction
5 Lost Employment Income Certification.docx Lost Employment Income Certification.docx Form and Instruction
6 Unreimbursed Medical Expenses Certification.docx Unreimbursed Medical Expenses Certification.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Benefits Package and Supporting Documentation	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	Lost Employment Income Certification - Estate.docx	Lost Employment Income Certification - Estate.docx	No		Paper Only
Form and Instruction	1	Certification of Status for Death Benefit - Alternative Calculation.docx	Certification of Status for Death Benefit - Alternative Calculation.docx	No		Paper Only
Form and Instruction	2	Certification of Status for Death Benefit - Standard Calculation.docx	Certification of Status for Death Benefit - Standard Calculation.docx	No		Paper Only
Form and Instruction	3	Death Benefit Certification of Relationship Survivor.docx	Death Benefit Certification of Relationship Survivor.docx	No		Paper Only
Form and Instruction	5	Lost Employment Income Certification.docx	Lost Employment Income Certification.docx	No		Paper Only
Form and Instruction	6	Unreimbursed Medical Expenses Certification.docx	Unreimbursed Medical Expenses Certification.docx	No		Paper Only
Instruction			Compensation Attachment 1.docx	Yes	No	Paper Only
Instruction			Compensation Attachment 1 for Reps.docx	Yes	No	Paper Only
Instruction			Compensation Attachment 1 for Estate.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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