Countermeasures Injury Compensation Program (CICP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Attachment 3 - Sur Survivor Attachment 3 - Death Benefit Certification of Relationship Redline	Form and Instruction	Modified	Available
Form Attachment 2 - Sur Certification of Status for Death Benefit - Alternative Calculation (redline)	Form and Instruction	Modified	Available
Form Attachment 2 - Sur Certification of Status for Death Benefit - Alternative Calculation (Clean)	Form and Instruction	Modified	Available
Form Attachment 1 - Sur Certification of Status for Death Benefit - Redline	Form and Instruction	Modified	Available
Form Attachment 1 - Sur Certifcation of Status for Death Benefit (clean)	Form and Instruction	Modified	Available
Form Attachment 3 - Est Lost Income Certification	Form and Instruction	Modified	Available
Form Attachment 2 - Est Unreimbursed Medical Expenses Certification (redline)	Form and Instruction	Modified	Available
Form Attachment 2 - Est Unreimbrused Medical Expenses Certification (Clean)	Form and Instruction	Modified	Available
Form Attachment 3 Lost Income Certification A (Redline)	Form and Instruction	Modified	Available
Form Attachment 3 Lost Employment Income Certification A (Clean)	Form and Instruction	Modified	Available
Form Attachment 2 Unreimbursed Medical Expenses Certification (Redline)	Form and Instruction	Modified	Available
Form Attachment 2 Unreimbursed Medical Expenses Certification A (Clean)	Form and Instruction	Modified	Available
Form 4.6 Certification of Status: Unreimbursed Medical Expenses	Form	Modified	Available
Form 4.5 Certification of Status: Lost Employment Income	Form	Modified	Available
Form 4.4 Certification of Status for Administrators of the Estate: Lost Employment Income	Form	Modified	Available
Form 4.3 Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient	Form	Modified	Available
Form 4.2 Certification of Status for Death Benefit - Standard Calculation	Form	Modified	Available
Form 4.1 Certification of Status for Death Benefit – Alternate Calculation	Form	Modified	Available
Form 1 Certification Form - Redline	Form	Modified	Available
Form 1 Certification Form - Clean	Form	Modified	Available
Form 3 Certification Form	Form	Modified	Available
Form 3 Additional Documentation and Certification	Form	Modified	Repair queued
Form 1 CICP Authorization Form Instructions in Spanish - Redline	Form and Instruction	Modified	Available
Form 1 CICP Authorization Form in Spanish - Redline	Form	Modified	Available
Form 2 CICP Authorization Form	Form and Instruction	Modified	Available
Form 2 Authorization for Use or Disclosure of Health Information Form	Form and Instruction	Modified	Repair queued
Form 1 CICP Request Form Instructions in Spanish - Redline	Form and Instruction	Modified	Available
Form 1 CICP Request Form (with Color) in Spanish - Redline	Form and Instruction	Modified	Available
Form 1A CICP Request Form Instructions	Form and Instruction	Modified	Available
Form 1 CICP Request Form	Form	Modified	Available
Form 1 Countermeasures Injury Compensation Program Request Package	Form	Modified	Repair queued
07. Medical Last Chance Letter.docx	Supplementary Document	Uploaded 2024-01-05	Available
07. Medical Last Chance Letter.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
10112023 - (06) Insufficient Records - Benefits Determination Letter - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Available
10112023 - (06) Insufficient Records - Benefits Determination Letter - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
10112023 - (05) Response Form - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Available
10112023 - (05) Response Form - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
10112023 - (04) Insufficient Documentation - Initial 60-day Letter - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Available
10112023 - (04) Insufficient Documentation - Initial 60-day Letter - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
10112023 - (03) Insufficient Documentation - Final 60-day Letter - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Available
10112023 - (03) Insufficient Documentation - Final 60-day Letter - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
10112023 - (02) Insufficient Documentation - Blank RFB Form - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Available
10112023 - (02) Insufficient Documentation - Blank RFB Form - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
10112023 - (01) Admin 60-day Letter Template - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Available
10112023 - (01) Admin 60-day Letter Template - CLEAN.docx	Supplementary Document	Uploaded 2024-01-05	Repair queued
01042024 - (00) OMB NonSubstantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-05	Available
01042024 - (00) OMB NonSubstantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-05	Repair queued
04062023 - Supporting Statement A - CICP 30-Day Extension Request OMB 0915-0334.docx	Supporting Statement A	Uploaded 2023-04-06	Available
04062023 - Supporting Statement A - CICP 30-Day Extension Request OMB 0915-0334.docx	Supporting Statement A	Uploaded 2023-04-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Survivor Attachment 3 - Death Benefit Certification of Relationship Redline
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Certification of Status for Death Benefit - Alternative Calculation (redline)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Certification of Status for Death Benefit - Alternative Calculation (Clean)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Certification of Status for Death Benefit - Redline
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Certifcation of Status for Death Benefit (clean)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Lost Income Certification
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Unreimbursed Medical Expenses Certification (redline)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Unreimbrused Medical Expenses Certification (Clean)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Lost Income Certification A (Redline)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Lost Employment Income Certification A (Clean)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Unreimbursed Medical Expenses Certification (Redline)
208418	Benefits Package and Supporting Documentation	Form and Instruction	Modified	Unreimbursed Medical Expenses Certification A (Clean)
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status: Unreimbursed Medical Expenses
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status: Lost Employment Income
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status for Administrators of the Estate: Lost Employment Income
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status for Death Benefit - Standard Calculation
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status for Death Benefit – Alternate Calculation
208418	Benefits Package and Supporting Documentation	Instruction	Modified
208417	Additional Documentation and Certification	Form	Modified	Certification Form - Redline
208417	Additional Documentation and Certification	Form	Modified	Certification Form - Clean
208417	Additional Documentation and Certification	Form	Modified	Certification Form
208417	Additional Documentation and Certification	Form	Modified
208416	Authorization for Use or Disclosure of Health Information Form	Form and Instruction	Modified	CICP Authorization Form Instructions in Spanish - Redline
208416	Authorization for Use or Disclosure of Health Information Form	Form	Modified	CICP Authorization Form in Spanish - Redline
208416	Authorization for Use or Disclosure of Health Information Form	Form and Instruction	Modified	CICP Authorization Form
208416	Authorization for Use or Disclosure of Health Information Form	Form and Instruction	Modified
194529	Countermeasures Injury Compensation Program Request Package	Form and Instruction	Modified	CICP Request Form Instructions in Spanish - Redline
194529	Countermeasures Injury Compensation Program Request Package	Form and Instruction	Modified	CICP Request Form (with Color) in Spanish - Redline
194529	Countermeasures Injury Compensation Program Request Package	Form and Instruction	Modified	CICP Request Form Instructions
194529	Countermeasures Injury Compensation Program Request Package	Form	Modified	CICP Request Form
194529	Countermeasures Injury Compensation Program Request Package	Form	Modified

ICR Details

OMB Control No: 0915-0334	ICR Reference No: 202401-0915-002
Status: Historical Active	Previous ICR Reference No: 202303-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No: 20201
Title: Countermeasures Injury Compensation Program (CICP)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/10/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/09/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	04/30/2026	04/30/2026
Responses	260	0	260
Time Burden (Hours)	1,327	0	1,327
Cost Burden (Dollars)	0	0	0

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Abstract: The Countermeasures Injury Compensation Program (CICP) provides compensation to eligible individuals (requesters) seriously injured by a covered countermeasure administered or used pursuant to a Public Readiness and Emergency Preparedness Act of 2005 (PREP Act) Declaration, or to their estates and/or survivors. The CICP requires the Request for Benefits Package to determine whether a requester is eligible for Program benefits (compensation) for their injury and if applicable, to calculate the amount of program benefits a requester is eligible to receive. The Request for Benefits Package includes the Request for Benefits Form and Authorization for Use or Disclosure of Health Information Form(s), as well as the injured countermeasure recipient’s medical records and supporting documentation. A requester who is an injured countermeasure recipient, the requester’s legal representative, or the estate or survivor(s) of an injured countermeasure recipient is responsible for submitting the Request for Benefits Package, as well as the injured countermeasure recipient’s medical records and supporting documentation.

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Authorizing Statute(s): US Code: 42 USC 247d-6d Name of Law: Public Readiness and Emergency Preparedness Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 358	01/04/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 17860	03/24/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Additional Documentation and Certification	1 , 1, 3	Certification Form ,   Certification Form - Clean ,   Certification Form - Redline
Authorization for Use or Disclosure of Health Information Form	1, 1, 2	CICP Authorization Form ,   CICP Authorization Form in Spanish - Redline ,   CICP Authorization Form Instructions in Spanish - Redline
Benefits Package and Supporting Documentation	Attachment 3 - Estate, Attachment 1 - Survivor, Attachment 2 - Survivor, Attachment 2 - Survivor, Attachment 3 - Survivor, Attachment 3, Attachment 2 - Estate, Attachment 2 - Estate, Attachment 1 - Survivor, 4.1, Attachment 2, Attachment 2, Attachment 3, 4.2, 4.3, 4.4, 4.5, 4.6	Certification of Status for Death Benefit – Alternate Calculation ,   Certification of Status for Death Benefit - Standard Calculation ,   Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient ,   Certification of Status for Administrators of the Estate: Lost Employment Income ,   Certification of Status: Lost Employment Income ,   Certification of Status: Unreimbursed Medical Expenses ,   Unreimbursed Medical Expenses Certification A (Clean) ,   Unreimbursed Medical Expenses Certification (Redline) ,   Lost Employment Income Certification A (Clean) ,   Lost Income Certification A (Redline) ,   Unreimbrused Medical Expenses Certification (Clean) ,   Unreimbursed Medical Expenses Certification (redline) ,   Lost Income Certification ,   Certifcation of Status for Death Benefit (clean) ,   Certification of Status for Death Benefit - Redline ,   Certification of Status for Death Benefit - Alternative Calculation (Clean) ,   Certification of Status for Death Benefit - Alternative Calculation (redline) ,   Survivor Attachment 3 - Death Benefit Certification of Relationship Redline
Countermeasures Injury Compensation Program Request Package	1, 1, 1A, 1	CICP Request Form ,   CICP Request Form Instructions ,   CICP Request Form (with Color) in Spanish - Redline ,   CICP Request Form Instructions in Spanish - Redline

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	260	260	0	0	0	0
Annual Time Burden (Hours)	1,327	1,327	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $46,710

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/09/2024

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