10112023 - (05) Response Form - CLEAN

Response Form (Optional)

Please return by submitting via the CICP’s electronic portal at injurycompensation.hrsa.gov (preferred). If unable to submit electronically, please send them to the following address:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

Please check the box of the statement that applies to you. Select only one option below.

I do not plan to submit any additional documentation. Please review my file for eligibility based on what has already been submitted, and do not wait the 60 days outlined in CICP’s letter.

I plan to submit the following additional documentation within 60 calendar days from the date of CICP’s letter.

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Name of Requester (Please print) CICP Case Number

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Signature