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.

Latest Forms, Documents, and Supporting Material
Document
Name
Form
Form
Form and Instruction
Form and Instruction
Form
Form
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Justification for No Material/Nonsubstantive Change
Justification for No Material/Nonsubstantive Change
Supporting Statement A
Supporting Statement A
All Historical Document Collections
Approved without change
 No material or nonsubstantive change to a currently approved collection 2024-01-09
Approved without change
 Extension without change of a currently approved collection 2023-03-24
Approved without change
 No material or nonsubstantive change to a currently approved collection 2021-10-06
Approved with change
 Extension without change of a currently approved collection 2020-01-16
Approved with change
 Extension without change of a currently approved collection 2016-09-16
Approved without change
 Revision of a currently approved collection 2013-08-29
Approved without change
 No material or nonsubstantive change to a currently approved collection 2011-11-23
Approved without change
 No material or nonsubstantive change to a currently approved collection 2011-11-04
Withdrawn and continue
 No material or nonsubstantive change to a currently approved collection 2011-10-25
Approved without change
 Revision of a currently approved collection 2011-10-25
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 DAttachment D Request for Benefits FormFillable FileableForm and instruction

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

© 2024 OMB.report | Privacy Policy