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 is listed under ICR 202603-0915-003.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
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 Recipient - 2 Recipient Package - Lost Employment Income - (Form)	Form
Form Recipient - 1 Recipient Package - Unreimbursed Medical Expenses - (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 3 Certification Form	Form
Form 2 CICP Authorization Form	Form
Form 2 CICP Authorization Form	Form
Form 1 CICP Request for Benefits Form	Form
Form 1 CICP Request for Benefits Form	Form
Insufficient Records - Benefits Determination Letter.docx	Supplementary Document
Insufficient Records - Benefits Determination Letter.docx	Supplementary Document
Insufficient Records - Benefits Determination Letter - Redline.pdf	Supplementary Document
Insufficient Records - Benefits Determination Letter - Redline.pdf	Supplementary Document
Insufficient Documentation Response Form.docx	Supplementary Document
Insufficient Documentation Response Form - Redline.pdf	Supplementary Document
Insufficient Documentation Response Form - Redline.pdf	Supplementary Document
Insufficient Documentation - Initial 60-day Letter.docx	Supplementary Document
Insufficient Documentation - Initial 60-day Letter.docx	Supplementary Document
Insufficient Documentation - Initial 60-day Letter - Redline.pdf	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 Form - Redline.pdf	Supplementary Document
Insufficient Documentation - Incomplete RFB.docx	Supplementary Document
Insufficient Documentation - Incomplete RFB.docx	Supplementary Document
Insufficient Documentation - Final 60-day Letter.docx	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	Supplementary Document
Admin 60-day Letter.docx	Supplementary Document
Admin 60-day Letter - Redline.pdf	Supplementary Document
Admin 60-day Letter - Redline.pdf	Supplementary Document
SSA - CICP Revision 0915-0334_03182026.docx	Supporting Statement A
SSA - CICP Revision 0915-0334_03182026.docx	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

Historical document collections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

OMB Details

Countermeasures Injury Compensation Program Request Package

Federal Enterprise Architecture: Health - Consumer Health and Safety

Information collection instruments
Form	Name	Electronic access	Type
Form 1	CICP Request for Benefits Form	Fillable Fileable	Form

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