Benefits Package and Supporting Documentation

Countermeasures Injury Compensation Program (CICP)

OMB: 0915-0334

IC ID: 208418

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Benefits Package and Supporting Documentation
 
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
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 – 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

Health Consumer Health and Safety

 

30 0
   
Individuals or Households
 
   80 %

  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 30 0 0 0 0 30
Annual IC Time Burden (Hours) 4 0 0 0 0 4
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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