Information Collection

Countermeasures Injury Compensation Program Request Package

IC 194529 under ICR 202303-0915-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 1 Countermeasures Injury Compensation Program Request Package	Form
1 CICP Request Form 03132023 - CICP Request Form - OMB 0915-0334.pdf	Form
1 CICP Request Form 03132023 - CICP Request Form - OMB 0915-0334.pdf	Form
1A CICP Request Form Instructions 03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF	Form and Instruction
1A CICP Request Form Instructions 03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF	Form and Instruction

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	CICP Request Form	03132023 - CICP Request Form - OMB 0915-0334.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	1A	CICP Request Form Instructions	03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: CICP System of Records Notice

FR Citation: 84 FR 28829

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	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

table that charts IC Documents
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.