Form F FORM Attachment F - Additional Documentation Form 2-27-2

OMB No. 0915-0334
Exp. XX/XX/20XX

Please check the box of the statement that applies to your case and return to the CICP in
the enclosed envelope. Select only one option below.
I will not submit any more documentation. Please review my file for medical eligibility
based on what has already been submitted, and do not wait the 60 days outlined in
CICP’s letter. The CICP will determine medical eligibility after receipt of this form and
inform the requester of the result and next steps.
My medical providers will update my CICP file by sending additional medical records to
CICP. I will contact them and ask them to send any recent records that have not yet been
sent and/or any records listed as missing in CICP’s letter that came with this form. I
understand that the CICP will provide 60 days from the date of the letter for the
submission of these records. The CICP will determine medical eligibility after this 60
day period and inform the requester of the result and next steps.

____________________________
Name of Requester (Please print)

_______________________
CICP Case Number

____________________________
Signature

Public Burden Statement: The purpose of this data collection is to gather information to allow the Secretary of
Health and Human Services to determine if requesters are eligible for Countermeasure Injury Compensation Program
(CICP) benefits. Requesters (or their representatives) must submit appropriate documentation forms and relevant
medical records as specified in Section 42 CFR 110.50-110.53 to the CICP. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this information collection is 0915-0334 and it is valid until XX/
XX/202X. This information collection is required to obtain or retain a benefit (42 CFR Part 110). Access to these
records is strictly limited to authorized users who are aware of their responsibilities under the Privacy Act and who
are required to maintain Privacy Act safeguards with respect to such records. The System of Records Notice for
Injury Compensation Programs, HHS/HRSA/HSB, System No. 09–15–0056, identifies authorized users. Public
reporting burden for this collection of information is estimated to average 3.5 hours per response, including the time
for reviewing instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room
14N136B, Rockville, Maryland, 20857 or [email protected].