Countermeasures Injury Compensation Program (CICP)

ICR 202110-0915-001

OMB: 0915-0334

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Unchanged
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2021-10-06
Supporting Statement A
2020-01-15
ICR Details
0915-0334 202110-0915-001
Received in OIRA 202001-0915-002
HHS/HSA 20201
Countermeasures Injury Compensation Program (CICP)
No material or nonsubstantive change to a currently approved collection   No
Regular 10/06/2021
  Requested Previously Approved
03/31/2023 03/31/2023
260 260
1,327 1,327
0 0

OMB approval of the information collection requirements for the Countermeasures Injury Compensation Program (CICP or Program). The CICP provides compensation to eligible individuals (requesters) who suffer serious injuries directly caused by a covered countermeasure administered or used pursuant to a PREP Act Declaration, or to their estates and/or survivors. The CICP requires the Request for Benefits Package, which includes the Request for Benefits Form and Authorization for Use or Disclosure of Health Information Form(s), as well as the injured countermeasure recipient’s medical records and supporting documentation to determine whether a requester is eligible for Program benefits (compensation) for their injury and if applicable, to calculate the amount of program benefits a requester is eligible for.

US Code: 42 USC 247d-6d Name of Law: Public Readiness and Emergency Preparedness Act
  
None

Not associated with rulemaking

  84 FR 33954 07/16/2019
85 FR 322 01/03/2020
No

  Total Request 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 260 260 0 0 0 0
Annual Time Burden (Hours) 1,327 1,327 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$41,355
No
    No
    No
No
No
No
No
Elyana Bowman 301 443-3983 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/06/2021


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