Smallpox Vaccine Injury Compensation Program

Documents and Forms

Document Name Document Type
Form request form Smallpox Vaccine Injury Compensation Program Form
0282 Request instructions.doc Instruction
request form request form 0282 Request Form.doc Form

Information Collection (IC) Details

View Information Collection (IC)

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

Is this a Common Form? No		IC Status: Modified

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	request form	request form	0282 Request Form.doc		Yes	No	Fillable Printable
Instruction			0282 Request 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	Previously Approved
Annual Number of Responses for this IC	25	-2,475	2,500
Annual IC Time Burden (Hours)	125	-7,375	7,500
Annual IC Cost Burden (Dollars)	0	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.