Form 1 CICP Request Form

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

COUNTERMEASURES INJURY COMPENSATION PROGRAM
REQUEST FOR BENEFITS FORM
The Countermeasures Injury Compensation Program (CICP) provides certain medical and lost employment income
benefits for individuals who were administered or used a covered countermeasure (such as 2009 H1N1 vaccine,
Tamiflu®, Relenza®, and peramivir, mechanical ventilator, N-95 Filter Mask, anthrax vaccine, smallpox vaccine, etc.)
and suffered a serious physical injury as a result. Individuals have one year from the date they were administered or used
the covered countermeasure to submit a Request for Benefits Form (Request Form) in order to be considered for benefits.
Although the CICP needs all the medical documentation that supports the injury in order to process the request,
requesters may submit only this Form in order to meet the filing deadline. The CICP may also provide death benefits
to certain survivors. The estate of a deceased individual may also qualify for certain medical and lost employment income
benefits.
Read the instructions before completing this Request for Benefits Form.

SECTION A. INJURED COUNTERMEASURE RECIPIENT

Fill in information about the person who was administered or used a covered countermeasure and may have had a serious
injury from the countermeasure.
First Name: ________________________Middle Initial: ______ Last Name: _____________________________
Date of Birth: ___________________________
Address: ____________________________________________________________________________________
City: _______________________________ State: ____________ Zip or Postal Code: ______________________
Country (if other than the United States of America):_________________________________________________
Telephone Number(s): _________________________________________________________________________
Email address: _______________________________________________________________________________
Type of countermeasure (e.g., 2009 H1N1 vaccine): _________________________________________________
Date(s) of the countermeasure administration or use that may have caused the injury: ______________________
Geographic location in which the countermeasure was administered or used (e.g., city, State):________________

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Last Updated: March 10, 2020

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

Describe the purpose for receiving the countermeasure (e.g., “There was an outbreak in my community”):

___________________________________________________________________________________________
Who administered it? (e.g., doctor, hospital, clinic, local health department):______________________________
Date of onset of the injury:_____________________________________________________________________
Describe the injury that may have resulted from the countermeasure:

If you are the injured countermeasure recipient, go to Section E and sign this Request Form.
If you are a survivor of a deceased injured countermeasure recipient who may have died as a result of the
countermeasure, go to Section B (Yellow).
If you are the executor or administrator of the estate of a deceased injured countermeasure recipient, regardless of
the cause of death, go to Section C (Blue).
If you are the legal or personal representative (including parent or guardian) of a person applying for Program
benefits, go to Section D (Orange).

Last Updated: March 10, 2020

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

SECTION B. SURVIVOR OF DECEASED INJURED COUNTERMEASURE RECIPIENT WHO MAY
HAVE DIED AS A RESULT OF THE COVERED COUNTERMEASURE
All information in Section B refers only to the survivor(s) of the individual identified in Section A, who is/are requesting
death benefits.
First Name: _________________ Middle Initial: ______ Last Name: _____________________________________
Date of Birth: __________________________
Address: ______________________________________________________________________________________
City: _________________________ State: _________Zip or Postal Code: ______________________________
Country (if other than the United States of America):___________________________________________________
Telephone Number(s): __________________________________________________________________________
Email address: ________________________________________________________________________________
The date the injured countermeasure recipient identified in Section A died: ________________________________
In order to be considered for Program benefits, a survivor must be in one of the categories described below. Check the
box that describes the person identified in Section B in relation to the individual identified in Section A.
Spouse
Eligible child (described in the instructions)
Dependent younger than the age of 18 (described in the instructions)
Beneficiary named in most recently executed life insurance policy (and there are no survivors in the categories
described above)
Parent (and there are no survivors in the categories described above)
Legal guardian of a deceased minor (and there are no survivors in the categories listed above)
Adult child (and there are no survivors in the categories described above)
Check the first box below if the requester is a sole survivor or the second box if there are other survivors described above.
or

To the best of my knowledge, there are no other survivors who may be eligible for a CICP death benefit payment;

There are other survivors who may be eligible for a CICP death benefits payment. I am providing their names and
their relationship to the person we survived. If this box is checked, list survivors. Use additional sheet(s), if necessary.
(Eligible survivor categories are listed above.)
Name: ____________________________________

Relationship: ________________________________

Name: ____________________________________

Relationship: ________________________________

Name: _____________________________________

Relationship: ________________________________

Name: _____________________________________

Relationship: ________________________________

Go to Section C (Blue) if you are also the executor or the administrator of the estate.
Go to Section D (Orange) if there is a legal or personal representative; otherwise, go to Section E to sign this Request
Form.

Last Updated: March 10, 2020

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

SECTION C. EXECUTOR OR ADMINISTRATOR OF THE ESTATE OF A DECEASED INJURED
COUNTERMEASURE RECIPIENT

The Program may provide medical and/or lost employment income benefits to the estate of a deceased individual
described in Section A, regardless of the cause of death. All information requested in Section C refers to the executor or
administrator of the estate only.
First Name: _________________ Middle Initial: ______ Last Name: _____________________________
Address: ______________________________________________________________________________
City: ______________________ State: __________ Zip or Postal Code:___________________________
Country (if other than the United States of America): __________________________________________
Telephone Number(s): __________________________________________________________________
Email address: ________________________________________________________________________
Go to Section D (Orange) if there is a legal or personal representative; otherwise, go to Section E to sign this Request
Form.

Last Updated: March 10, 2020

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

SECTION D. LEGAL OR PERSONAL REPRESENTATIVE (including parent or guardian)

If you are the legal or personal representative of a minor or adult who does not have legal capacity to receive payments,
complete Section D. Otherwise, a person requesting benefits does not need to have a legal or personal representative, but
may choose to do so. All communications will generally be conducted with the representative, if one is identified. The
CICP reserves the right to communicate with the requester if necessary.
The CICP will not pay or reimburse any fees or costs incurred by using a representative.
All Information in Section D refers to the legal or personal representative.
First Name: _________________ Middle Initial: ______ Last Name:______________________________
Address: ______________________________________________________________________________
City: _____________________ State: ____________Zip or Postal Code: __________________________
Country (if other than the United States of America): __________________________________________
Telephone Number(s): __________________________________________________________________
Email address: ________________________________________________________________________
Relationship to the person applying for Program benefits (e.g., parent, lawyer):_____________________
Is the person you are representing a minor or an adult who does not have the legal capacity to receive payments?
Yes
No
Go to Section E to sign this Request Form.

Last Updated: March 10, 2020

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

SECTION E. SIGNATURE
To be signed by the requester who is: (a) the injured countermeasure recipient identified in Section A; or
(b) the survivor identified in Section B; or (c) the executor or administrator of the estate identified in
Section C. If the requester does not have the legal capacity to receive a Program payment, then the
personal or legal representative identified in Section D must sign on his or her behalf.
By signing this Form:

1) I hereby certify that the information provided in this Request Form is true and accurate to the best of my knowledge.
Further, I understand that false statements or claims made in connection with this Request Form, including subsequent
information and documentation submitted in connection with this Request Form, may result in fines, imprisonment and/or
any other remedy, including civil remedies, available by law to the United States.
2) I will provide updated information (including, but not limited to medical records, employment income records, and
change of address) until the Program has made its final decision.
3) (Check one):
I have the legal capacity to receive Program payments; or
I represent someone who does not have the legal capacity to receive Program payments and I am signing
below.
Name (Print clearly): ___________________________________________________________
Signature: ________________________________________ Date: ______________________

Last Updated: March 10, 2020

Form No: CICP-1

OMB Control Number: 0915-0334
Expiration Date: 3/31/2023

You can submit your Request Form and all the required documentation to the CICP by U.S. mail, a private
courier service, or commercial carrier to:
U.S. Department of Health and Human Services
Health Resources and Services Administration
Countermeasures Injury Compensation Program
5600 Fishers Lane, 08N146B
Rockville, MD 20857
For Program information and to obtain an additional copy of this Form and the instructions for completing it, visit the
CICP Web site at www.hrsa.gov/cicp, call 1-855-266-2427 (1-855-266-CICP), or email: [email protected]. Check the
Program Web site to see if this Form can be submitted electronically.
PRIVACY ACT STATEMENT
Section 319F-4 of the Public Health Service Act (PHS Act), Public Law 109-148 (42 U.S.C. 247d-6e), and the Debt
Collection Improvement Act of 1996 authorize collection of this information. It will be used to determine your eligibility
to receive benefits. This information will be disclosed to the U.S. Department of Health and Human Services and its
consultants; and Federal, State, or local law enforcement agencies, if the Government becomes aware of a possible
violation of civil or criminal law; and for certain medical research purposes when consistent with the purposes for which
the Program was formed, i.e., to make determinations concerning alleged covered countermeasure injury associations and
to provide compensation to individuals injured by covered countermeasures. Furnishing the information on this Form is
voluntary, but failure to do so may delay or prevent the receipt of a payment. The information collected will be
maintained confidentially pursuant to the Privacy Act, 5 USC Section 552a, as amended.
PUBLIC BURDEN STATEMENT
Public Burden Statement: The purpose of this data collection is to gather information to allow the Secretary of Health and
Human Services to determine if requesters are eligible for Countermeasure Injury Compensation Program (CICP)
benefits. Requesters (or their representatives) must submit appropriate documentation forms and relevant medical records
as specified in Section 42 CFR 110.50-110.53 to the CICP. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control number for this information collection is 0915-0334 and it is valid until 03/31/2023. This information collection is
required to obtain or retain a benefit (42 CFR Part 110). Access to these records is strictly limited to authorized users who
are aware of their responsibilities under the Privacy Act and who are required to maintain Privacy Act safeguards with
respect to such records. The System of Records Notice for Injury Compensation Programs, HHS/HRSA/HSB, System
No. 09–15–0056, identifies authorized users. Public reporting burden for this collection of information is estimated to
average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance
Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]

Last Updated: March 10, 2020