Countermeasures Injury Compensation Program Request Package

Countermeasures Injury Compensation Program (CICP)

OMB: 0915-0334

IC ID: 194529

Information Collection (IC) Details

View Information Collection (IC)

Countermeasures Injury Compensation Program Request Package
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL 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

Health Consumer Health and Safety

 

100 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100 0 0 0 0 100
Annual IC Time Burden (Hours) 1,100 0 0 0 0 1,100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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