OMB
.report
Search
Benefits Package and Supporting Documentation
Countermeasures Injury Compensation Program (CICP)
OMB: 0915-0334
IC ID: 208418
OMB.report
HHS/HSA
OMB 0915-0334
ICR 202603-0915-003
IC 208418
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Benefits Package and Supporting Documentation
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
Definitions for Survivorship (New).docx
Yes
Yes
Fillable Fileable
Form
Survivor - Form 2
Survivor Package - Identifying Third Party Players
Survivor Package - Identifying Third Party Payers - Form 2 (New).docx
Yes
Yes
Fillable Fileable
Form
Survivor - Attachment 1
Survivor Package - Survivor Benefit Eligibility and Priority
Survivor Package - Survivor Benefit Eligibility and Priority- Attachment 1 (New).docx
Yes
Yes
Fillable Fileable
Form
Survivor - Form 3
Survivor Package - Standard or Alternative Calculation Selection (New)
Survivor Package - Standard or Alternative Calculation Selection - Form 3 (New).docx
Yes
Yes
Fillable Fileable
Form
Survivor - Form 1
Survivor Package - Certification of Relationship.docx
Survivor Package - Certification of Relationship.docx
Yes
Yes
Fillable Fileable
Instruction
Survivor Package - Compensation Letter.docx
Yes
Yes
Fillable Fileable
Instruction
Estate Package - Compensation Letter.docx
Yes
Yes
Fillable Fileable
Instruction
Recipient Package - Compensation Letter.docx
Yes
Yes
Fillable Fileable
Form
Estate - 1
Estate Package - Unreimbursed Medical Expenses (Form)
Estate Package - Unreimbursed Medical Expenses (Form).docx
Yes
Yes
Fillable Fileable
Form
Estate - 2
Estate Package - Lost Employment Income (Form)
Estate Package - Lost Employment Income (Form).docx
Yes
Yes
Fillable Fileable
Form
Recipient - 1
Recipient Package - Unreimbursed Medical Expenses - (Form)
Recipient Package - Unreimbursed Medical Expenses - (Form).docx
Yes
Yes
Fillable Fileable
Form
Recipient - 2
Recipient Package - Lost Employment Income - (Form)
Recipient Package - Lost Employment Income - (Form).docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
30
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
80 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
30
0
0
0
0
30
Annual IC Time Burden (Hours)
300
0
296
0
0
4
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Survivor Package - Certification of Relationship - Redline
Survivor Package - Certification of Relationship - Redline.pdf
03/18/2026
Survivor Package - Compensation Letter - Redline
Survivor Package - Compensation Letter -Redline.pdf
03/18/2026
Estate Package - Compensation Letter - Redline
Estate Package - Compensation Letter - Redline.pdf
03/18/2026
Estate Package - Lost Employment Income (Form) - Redline
Estate Package - Lost Employment Income (Form) - Redline.pdf
03/18/2026
Estate Package - Unreimbursed Medical Expenses (Form) - Redline
Estate Package - Unreimbursed Medical Expenses (Form) - Redline.pdf
03/18/2026
Recipient Package - Compensation Letter - Redline
Recipient Package - Compensation Letter - Redline.pdf
03/18/2026
Recipient Package - Lost Employment Income - (Form) - Redline
Recipient Package - Lost Employment Income - (Form) - Redline.pdf
03/18/2026
Recipient Package - Unreimbursed Medical Expenses - (Form) - Redline
Recipient Package - Unreimbursed Medical Expenses - (Form) - Redline.pdf
03/18/2026
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.