Countermeasures Injury Compensation Program (CICP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Recipient - 2 Recipient Package - Lost Employment Income - (Form)	Form	Modified	Available
Form Recipient - 1 Recipient Package - Unreimbursed Medical Expenses - (Form)	Form	Modified	Available
Form Estate - 2 Estate Package - Lost Employment Income (Form)	Form	Modified	Available
Form Estate - 1 Estate Package - Unreimbursed Medical Expenses (Form)	Form	Modified	Available
Form Survivor - Form 1 Survivor Package - Certification of Relationship.docx	Form	Modified	Available
Form Survivor - Form 3 Survivor Package - Standard or Alternative Calculation Selection (New)	Form	Modified	Available
Form Survivor - Attachm Survivor Package - Survivor Benefit Eligibility and Priority	Form	Modified	Available
Form Survivor - Form 2 Survivor Package - Identifying Third Party Players	Form	Modified	Available
Form Recipient - 2 Recipient Package - Lost Employment Income - (Form)	Form	Modified	Available
Form Recipient - 1 Recipient Package - Unreimbursed Medical Expenses - (Form)	Form	Modified	Available
Form Estate - 2 Estate Package - Lost Employment Income (Form)	Form	Modified	Available
Form Estate - 1 Estate Package - Unreimbursed Medical Expenses (Form)	Form	Modified	Available
Form Survivor - Form 1 Survivor Package - Certification of Relationship.docx	Form	Modified	Available
Form Survivor - Form 3 Survivor Package - Standard or Alternative Calculation Selection (New)	Form	Modified	Available
Form Survivor - Attachm Survivor Package - Survivor Benefit Eligibility and Priority	Form	Modified	Available
Form Survivor - Form 2 Survivor Package - Identifying Third Party Players	Form	Modified	Available
Form 3 Certification Form	Form	Modified	Available
Form 3 Certification Form	Form	Modified	Available
Form 2 CICP Authorization Form	Form	Modified	Available
Form 2 CICP Authorization Form	Form	Modified	Available
Form 1 CICP Request for Benefits Form	Form	Modified	Available
Form 1 CICP Request for Benefits Form	Form	Modified	Available
Insufficient Records - Benefits Determination Letter.docx	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Records - Benefits Determination Letter.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Records - Benefits Determination Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Records - Benefits Determination Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation Response Form.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation Response Form.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation Response Form - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation Response Form - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation - Initial 60-day Letter.docx	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation - Initial 60-day Letter.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation - Initial 60-day Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation - Initial 60-day Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation - Incomplete RFB Form - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation - Incomplete RFB Form - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation - Incomplete RFB.docx	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation - Incomplete RFB.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation - Final 60-day Letter.docx	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation - Final 60-day Letter.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Insufficient Documentation - Final 60-day Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Available
Insufficient Documentation - Final 60-day Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Repair queued
Admin 60-day Letter.docx	Supplementary Document	Uploaded 2026-03-18	Available
Admin 60-day Letter.docx	Supplementary Document	Uploaded 2026-03-18	Repair queued
Admin 60-day Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Available
Admin 60-day Letter - Redline.pdf	Supplementary Document	Uploaded 2026-03-18	Repair queued
SSA - CICP Revision 0915-0334_03182026.docx	Supporting Statement A	Uploaded 2026-03-18	Available
SSA - CICP Revision 0915-0334_03182026.docx	Supporting Statement A	Uploaded 2026-03-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208418	Benefits Package and Supporting Documentation	Form	Modified	Recipient Package - Lost Employment Income - (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Recipient Package - Unreimbursed Medical Expenses - (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Estate Package - Lost Employment Income (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Estate Package - Unreimbursed Medical Expenses (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Certification of Relationship.docx
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Standard or Alternative Calculation Selection (New)
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Survivor Benefit Eligibility and Priority
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Identifying Third Party Players
208418	Benefits Package and Supporting Documentation	Form	Modified	Recipient Package - Lost Employment Income - (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Recipient Package - Unreimbursed Medical Expenses - (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Estate Package - Lost Employment Income (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Estate Package - Unreimbursed Medical Expenses (Form)
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Certification of Relationship.docx
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Standard or Alternative Calculation Selection (New)
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Survivor Benefit Eligibility and Priority
208418	Benefits Package and Supporting Documentation	Form	Modified	Survivor Package - Identifying Third Party Players
208418	Benefits Package and Supporting Documentation	Instruction	Modified
208417	Additional Documentation and Certification	Form	Modified	Certification Form
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	Modified	CICP Authorization Form
208416	Authorization for Use or Disclosure of Health Information Form	Form	Modified	CICP Authorization Form
208416	Authorization for Use or Disclosure of Health Information Form	Form	Modified
194529	Countermeasures Injury Compensation Program Request Package	Form	Modified	CICP Request for Benefits Form
194529	Countermeasures Injury Compensation Program Request Package	Form	Modified	CICP Request for Benefits Form
194529	Countermeasures Injury Compensation Program Request Package	Instruction	Modified

ICR Details

OMB Control No: 0915-0334	ICR Reference No: 202603-0915-003
Status: Active	Previous ICR Reference No: 202401-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 20201
Title: Countermeasures Injury Compensation Program (CICP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/20/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/19/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2029	36 Months From Approved	04/30/2026
Responses	1,074	0	260
Time Burden (Hours)	5,223	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:
	90 FR 58568	12/17/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 13042	03/18/2026
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	3	Certification Form
Authorization for Use or Disclosure of Health Information Form	2	CICP Authorization Form
Benefits Package and Supporting Documentation	Survivor - Form 2, Survivor - Attachment 1, Survivor - Form 3, Survivor - Form 1, Estate - 1, Estate - 2, Recipient - 1, Recipient - 2	Survivor Package - Identifying Third Party Players ,   Survivor Package - Survivor Benefit Eligibility and Priority ,   Survivor Package - Standard or Alternative Calculation Selection (New) ,   Survivor Package - Certification of Relationship.docx ,   Estate Package - Unreimbursed Medical Expenses (Form) ,   Estate Package - Lost Employment Income (Form) ,   Recipient Package - Unreimbursed Medical Expenses - (Form) ,   Recipient Package - Lost Employment Income - (Form)
Countermeasures Injury Compensation Program Request Package	1	CICP Request for Benefits Form

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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	1,074	260	0	814	0	0
Annual Time Burden (Hours)	5,223	1,327	0	3,896	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The burden hours are expected to increase from 1,327 hours to 5,223 hours, due to an increase in the expected number of respondents (from 260 to 1,074). The reason for the increase is because since the last package approval there was an increase in the number of RFB packages submitted to HRSA annually.

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Annual Cost to Federal Government: $2,417,385

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: 03/19/2026

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