Additional Documentation and Certification

Countermeasures Injury Compensation Program (CICP)

⚠️ Notice: This information collection may be referencing outdated material.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 3 Additional Documentation and Certification Form
3 Certification Form 03142023 - Certification Form.docx Form
3 Certification Form 03142023 - Certification Form.docx Form

Information Collection (IC) Details

IC Title:	Additional Documentation and Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	Certification Form	03142023 - Certification Form.docx		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: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	23	23
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.