Countermeasures Injury Compensation Program (CICP)

ICR 202303-0915-005

OMB: 0915-0334

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0915-0334 can be found here:

2024-01-09 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form 3 Additional Documentation and Certification Form	Modified
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction	Modified
Form 1 Countermeasures Injury Compensation Program Request Package Form	Modified
03162023 - Supporting Statement A - CICP 30-Day Extension Request OMB 0915-0334.docx Supporting Statement A	2023-03-24

IC Document Collections

IC ID	Document Title	Status
208418	Benefits Package and Supporting Documentation Instruction	Modified
208417	Additional Documentation and Certification Form	Modified
208416	Authorization for Use or Disclosure of Health Information Form Form and Instruction	Modified
194529	Countermeasures Injury Compensation Program Request Package Form	Modified

ICR Details

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