Countermeasures Injury Compensation Program Request Package

Countermeasures Injury Compensation Program (CICP)

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	Yes	Fillable Fileable
Form	1				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: 360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	360	260	100
Annual IC Time Burden (Hours)	3,960	2,860	1,100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CICP Request for Benefits Form - Instructions - Redline		03/18/2026
CICP Request for Benefits Form - Redline		03/18/2026

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

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