Smallpox Vaccine Injury Compensation Program Certification form

Smallpox Vaccine Injury Compensation Program

Documents and Forms

Document Name Document Type
Form certification Smallpox Vaccine Injury Compensation Program Certification form Form
0282 certification instructions.doc Instruction
certification certification 0282 certification.doc Form

Information Collection (IC) Details

IC Title:	Smallpox Vaccine Injury Compensation Program Certification form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 102

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	certification	certification	0282 certification.doc		Yes	No	Fillable Printable
Instruction			0282 certification instructions.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Smallpox Vaccine Injury Compensation Program, HHS/HRSA/OSP	FR Citation: 68 FR 62301

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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