OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Countermeasures Injury Compensation Program Request Package

IC 194529 under ICR 202603-0915-003 · OMB 0915-0334.

Documents and Forms
Document Name
Document Type
Form
Form
Instruction
Instruction
Form
Form
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Countermeasures Injury Compensation Program Request Package
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CICP Request for Benefits Form - Instructions.docx Yes Yes Fillable Fileable
Form 1 CICP Request for Benefits Form CICP Request for Benefits Form.docx Yes Yes Fillable Fileable

Health Consumer Health and Safety

CICP System of Records Notice   84 FR 28829

360 0
   
Individuals or Households
 
   80 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 360 0 260 0 0 100
Annual IC Time Burden (Hours) 3,960 0 2,860 0 0 1,100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CICP Request for Benefits Form - Instructions - Redline CICP Request for Benefits Form - Instructions - Redline.pdf 03/18/2026
CICP Request for Benefits Form - Redline CICP Request for Benefits Form - Redline.pdf 03/18/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].