Countermeasures Injury Compensation Program (CICP)

OMB 0915-0334

OMB 0915-0334

OMB approval of the information collection requirements for the Countermeasures Injury Compensation Program (CICP or Program). The CICP provides compensation to eligible individuals (requesters) who suffer serious injuries directly caused by a covered countermeasure administered or used pursuant to a PREP Act Declaration, or to their estates and/or survivors. The CICP requires the Request for Benefits Package, which 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 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 for.

The latest form for Countermeasures Injury Compensation Program (CICP) expires 2023-03-31 and can be found here.

OMB Details

Countermeasures Injury Compensation Program Request Package

Federal Enterprise Architecture: Health - Consumer Health and Safety

Form DAttachment D Request for Benefits FormFillable FileableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.

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