Information Collection

Countermeasures Injury Compensation Program Request Package

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 CICP Request for Benefits Form Countermeasures Injury Compensation Program Request Package	Form
Form 1 CICP Request for Benefits Form Countermeasures Injury Compensation Program Request Package	Form
CICP Request for Benefits Form - Instructions.docx	Instruction
CICP Request for Benefits Form - Instructions.docx	Instruction
1 CICP Request for Benefits Form CICP Request for Benefits Form.docx	Form
1 CICP Request for Benefits Form CICP Request for Benefits Form.docx	Form
CICP Request for Benefits Form - Instructions - Redline.pdf CICP Request for Benefits Form - Instructions - Redline	IC Document
CICP Request for Benefits Form - Instructions - Redline.pdf CICP Request for Benefits Form - Instructions - Redline	IC Document
CICP Request for Benefits Form - Redline.pdf CICP Request for Benefits Form - Redline	IC Document
CICP Request for Benefits Form - Redline.pdf CICP Request for Benefits Form - Redline	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	Yes	Fillable Fileable
Form	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: CICP System of Records Notice

FR Citation: 84 FR 28829

Number of Respondents: 360

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	360	260	100
Annual IC Time Burden (Hours)	3,960	2,860	1,100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CICP Request for Benefits Form - Instructions - Redline		03/18/2026
CICP Request for Benefits Form - Redline		03/18/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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