Countermeasures Injury Compensation Program Request Package

Countermeasures Injury Compensation Program (CICP)

Documents and Forms

Document Name Document Type
Form 1 Countermeasures Injury Compensation Program Request Package Form
Form 1 Countermeasures Injury Compensation Program Request Package Form
1 CICP Request Form 03132023 - CICP Request Form - OMB 0915-0334.pdf Form
1 CICP Request Form 03132023 - CICP Request Form - OMB 0915-0334.pdf Form
1A CICP Request Form Instructions 03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF Form and Instruction
1A CICP Request Form Instructions 03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF Form and Instruction
1 CICP Request Form (with Color) in Spanish - Redline 10112023 - (21) CICP Request Form (with color) 2020 in Spanish - REDLINE.docx Form and Instruction
1 CICP Request Form (with Color) in Spanish - Redline 10112023 - (21) CICP Request Form (with color) 2020 in Spanish - REDLINE.docx Form and Instruction
1 CICP Request Form Instructions in Spanish - Redline 10112023 - (22) CICP Request Form Instructions in Spanish - REDLINE.docx Form and Instruction
1 CICP Request Form Instructions in Spanish - Redline 10112023 - (22) CICP Request Form Instructions in Spanish - REDLINE.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Countermeasures Injury Compensation Program Request Package	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	CICP Request Form	03132023 - CICP Request Form - OMB 0915-0334.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1A	CICP Request Form Instructions	03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF	Yes	Yes	Fillable Fileable
Form and Instruction	1	CICP Request Form (with Color) in Spanish - Redline	10112023 - (21) CICP Request Form (with color) 2020 in Spanish - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	CICP Request Form Instructions in Spanish - Redline	10112023 - (22) CICP Request Form Instructions in Spanish - REDLINE.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: CICP System of Records Notice	FR Citation: 84 FR 28829

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	1,100	1,100
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.