Information Collection

Countermeasures Injury Compensation Program Request Package

IC 194529 under ICR 202110-0915-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form D Countermeasures Injury Compensation Program Request Package Form and Instruction
Final CICP Request Form Instructions_sp.pdf Instruction
Final CICP Request Form Instructions_sp.pdf Instruction
D Attachment D Request for Benefits Form Final CICP Request Form (with color) 2020.docx Form and Instruction
D Attachment D Request for Benefits Form Final CICP Request Form (with color) 2020.docx Form and Instruction
D - Spanish Final CICP Request Form (with color)_SPANISH.pdf Final CICP Request Form (with color)_sp.pdf Form
D - Spanish Final CICP Request Form (with color)_SPANISH.pdf Final CICP Request Form (with color)_sp.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	D	Attachment D Request for Benefits Form	Final CICP Request Form (with color) 2020.docx	Yes	Yes	Fillable Fileable
Instruction			Final CICP Request Form Instructions_sp.pdf	Yes	Yes	Fillable Fileable
Form	D - Spanish	Final CICP Request Form (with color)_SPANISH.pdf	Final CICP Request Form (with color)_sp.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	100
Annual IC Time Burden (Hours)	1,100	1,100
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.