OMB control number

Countermeasures Injury Compensation Program (CICP)

OMB 0915-0334 · HHS/HSA.

OMB 0915-0334

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.

The latest form for Countermeasures Injury Compensation Program (CICP) expires 2029-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form Recipient - 2 Recipient Package - Lost Employment Income - (Form) Form
Form Recipient - 1 Recipient Package - Unreimbursed Medical Expenses - (Form) Form
Form Estate - 2 Estate Package - Lost Employment Income (Form) Form
Form Estate - 1 Estate Package - Unreimbursed Medical Expenses (Form) Form
Form Survivor - Form 1 Survivor Package - Certification of Relationship.docx Form
Form Survivor - Form 3 Survivor Package - Standard or Alternative Calculation Selection (New) Form
Form Survivor - Attachm Survivor Package - Survivor Benefit Eligibility and Priority Form
Form Survivor - Form 2 Survivor Package - Identifying Third Party Players Form
Form 3 Certification Form Form
Form 2 CICP Authorization Form Form
Form 1 CICP Request for Benefits Form Form
Insufficient Records - Benefits Determination Letter.docx Supplementary Document
Insufficient Records - Benefits Determination Letter - Redline.pdf Supplementary Document
Insufficient Documentation Response Form.docx (document unavailable) Supplementary Document
Insufficient Documentation Response Form.docx (document unavailable) Supplementary Document
Insufficient Documentation Response Form - Redline.pdf (document unavailable) Supplementary Document
Insufficient Documentation Response Form - Redline.pdf (document unavailable) Supplementary Document
Insufficient Documentation - Initial 60-day Letter.docx (document unavailable) Supplementary Document
Insufficient Documentation - Initial 60-day Letter.docx (document unavailable) Supplementary Document
Insufficient Documentation - Initial 60-day Letter - Redline.pdf Supplementary Document
Insufficient Documentation - Incomplete RFB Form - Redline.pdf Supplementary Document
Insufficient Documentation - Incomplete RFB.docx (document unavailable) Supplementary Document
Insufficient Documentation - Incomplete RFB.docx (document unavailable) Supplementary Document
Insufficient Documentation - Final 60-day Letter.docx Supplementary Document
Insufficient Documentation - Final 60-day Letter - Redline.pdf Supplementary Document
Insufficient Documentation - Final 60-day Letter - Redline.pdf Supplementary Document
Admin 60-day Letter.docx (document unavailable) Supplementary Document
Admin 60-day Letter.docx (document unavailable) Supplementary Document
Admin 60-day Letter - Redline.pdf Supplementary Document
SSA - CICP Revision 0915-0334_03182026.docx (document unavailable) Supporting Statement A
SSA - CICP Revision 0915-0334_03182026.docx (document unavailable) Supporting Statement A
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Form
Benefits Package and Supporting Documentation Instruction
Additional Documentation and Certification Form
Additional Documentation and Certification Form
Additional Documentation and Certification Form
Authorization for Use or Disclosure of Health Information Form Form
Authorization for Use or Disclosure of Health Information Form Form
Authorization for Use or Disclosure of Health Information Form Form
Countermeasures Injury Compensation Program Request Package Form
Countermeasures Injury Compensation Program Request Package Form
Countermeasures Injury Compensation Program Request Package Instruction

All Historical Document Collections

202603-0915-003	Revision of a currently approved collection	2026-03-19
202401-0915-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-01-09
202303-0915-005 Approved without change	Extension without change of a currently approved collection	2023-03-24
202110-0915-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2021-10-06
202001-0915-002 Approved with change	Extension without change of a currently approved collection	2020-01-16
201609-0915-001 Approved with change	Extension without change of a currently approved collection	2016-09-16
201308-0915-005 Approved without change	Revision of a currently approved collection	2013-08-29
201111-0915-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2011-11-23
201111-0915-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2011-11-04
201110-0915-002 Withdrawn and continue	No material or nonsubstantive change to a currently approved collection	2011-10-25
201110-0915-001 Approved without change	Revision of a currently approved collection	2011-10-25
201009-0915-004 Preapproved	New collection (Request for a new OMB Control Number)	2010-09-10

OMB Details

Countermeasures Injury Compensation Program Request Package

Federal Enterprise Architecture: Health - Consumer Health and Safety

Form 1

CICP Request for Benefits Form

Fillable Fileable

Form

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