Information Collection

Benefits Package and Supporting Documentation

IC 208418 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Compensation Attachment 1.docx Instruction
Compensation Attachment 1.docx Instruction
Compensation Attachment 1 for Reps.docx Instruction
Compensation Attachment 1 for Reps.docx Instruction
Compensation Attachment 1 for Estate.docx Instruction
Compensation Attachment 1 for Estate.docx Instruction
4.1 Certification of Status for Death Benefit – Alternate Ca Certification of Status for Death Benefit - Alternative Calculation.docx Form
4.1 Certification of Status for Death Benefit – Alternate Ca Certification of Status for Death Benefit - Alternative Calculation.docx Form
4.2 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation.docx Form
4.2 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation.docx Form
4.3 Certification of Survivor Relationship to Deceased Injur Death Benefit Certification of Relationship Survivor.docx Form
4.3 Certification of Survivor Relationship to Deceased Injur Death Benefit Certification of Relationship Survivor.docx Form
4.4 Certification of Status for Administrators of the Estate Lost Employment Income Certification - Estate.docx Form
4.4 Certification of Status for Administrators of the Estate Lost Employment Income Certification - Estate.docx Form
4.5 Certification of Status: Lost Employment Income Lost Employment Income Certification.docx Form
4.5 Certification of Status: Lost Employment Income Lost Employment Income Certification.docx Form
4.6 Certification of Status: Unreimbursed Medical Expenses Unreimbursed Medical Expenses Certification.docx Form
4.6 Certification of Status: Unreimbursed Medical Expenses Unreimbursed Medical Expenses Certification.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Benefits Package and Supporting Documentation	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
Instruction			Compensation Attachment 1.docx	Yes	Yes	Printable Only
Instruction			Compensation Attachment 1 for Reps.docx	Yes	Yes	Printable Only
Instruction			Compensation Attachment 1 for Estate.docx	Yes	Yes	Printable Only
Form	4.1	Certification of Status for Death Benefit â Alternate Calculation	Certification of Status for Death Benefit - Alternative Calculation.docx	Yes	Yes	Printable Only
Form	4.2	Certification of Status for Death Benefit - Standard Calculation	Certification of Status for Death Benefit - Standard Calculation.docx	Yes	Yes	Printable Only
Form	4.3	Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient	Death Benefit Certification of Relationship Survivor.docx	Yes	Yes	Printable Only
Form	4.4	Certification of Status for Administrators of the Estate: Lost Employment Income	Lost Employment Income Certification - Estate.docx	Yes	Yes	Printable Only
Form	4.5	Certification of Status: Lost Employment Income	Lost Employment Income Certification.docx	Yes	Yes	Printable Only
Form	4.6	Certification of Status: Unreimbursed Medical Expenses	Unreimbursed Medical Expenses Certification.docx	Yes	Yes	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

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)	4	4
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.