Countermeasures Injury Compensation Program (CICP)

ICR 202401-0915-002

OMB: 0915-0334

Federal Form Document

Forms and Documents

Document Name	Status
Form 3 Additional Documentation and Certification Form	Modified
Form 3 Additional Documentation and Certification Form	Modified
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction	Modified
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction	Modified
Form 1 Countermeasures Injury Compensation Program Request Package Form	Modified
Form 1 Countermeasures Injury Compensation Program Request Package Form	Modified
07. Medical Last Chance Letter.docx Supplementary Document	2024-01-05
07. Medical Last Chance Letter.docx Supplementary Document	2024-01-05
10112023 - (06) Insufficient Records - Benefits Determination Letter - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (06) Insufficient Records - Benefits Determination Letter - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (05) Response Form - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (05) Response Form - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (04) Insufficient Documentation - Initial 60-day Letter - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (04) Insufficient Documentation - Initial 60-day Letter - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (03) Insufficient Documentation - Final 60-day Letter - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (03) Insufficient Documentation - Final 60-day Letter - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (02) Insufficient Documentation - Blank RFB Form - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (02) Insufficient Documentation - Blank RFB Form - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (01) Admin 60-day Letter Template - CLEAN.docx Supplementary Document	2024-01-05
10112023 - (01) Admin 60-day Letter Template - CLEAN.docx Supplementary Document	2024-01-05
01042024 - (00) OMB NonSubstantive Change Request.docx Justification for No Material/Nonsubstantive Change	2024-01-05
01042024 - (00) OMB NonSubstantive Change Request.docx Justification for No Material/Nonsubstantive Change	2024-01-05
04062023 - Supporting Statement A - CICP 30-Day Extension Request OMB 0915-0334.docx Supporting Statement A	2023-04-06
04062023 - Supporting Statement A - CICP 30-Day Extension Request OMB 0915-0334.docx Supporting Statement A	2023-04-06

IC Document Collections

IC ID	Document Title	Status
208418	Benefits Package and Supporting Documentation Instruction	Modified
208417	Additional Documentation and Certification Form	Modified
208417	Additional Documentation and Certification Form	Modified
208416	Authorization for Use or Disclosure of Health Information Form Form and Instruction	Modified
208416	Authorization for Use or Disclosure of Health Information Form Form and Instruction	Modified
194529	Countermeasures Injury Compensation Program Request Package Form	Modified
194529	Countermeasures Injury Compensation Program Request Package Form	Modified