Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Additional Documentation and Certification New 30 23 0 Form 1 Additional Documentation and Certification
Authorization for Use or Disclosure of Health Information Form New 100 200 0 Form and Instruction 1 Authorization for Use or Disclosure of Health Information Form
Benefits Package and Supporting Documentation New 30 4 0 Form and Instruction 1 Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)
Form and Instruction 2 Certification of Status for Death Benefit - Standard Calculation (Attachment 1)
Form and Instruction 3 Compensation Attachment 1 for Estate
Form and Instruction 4 Compensation Attachment 1 for Reps
Form and Instruction 5 Compensation Attachment 1
Form and Instruction 6 Death Benefit Certification of Relationship (Survivor Attach 3)
Form and Instruction 7 Lost Employment Income Certification - Estate (attatchment 3)
Form and Instruction 8 Lost Employment Income Certification (Attach 3)
Form and Instruction 9 Unreimbursed Medical Expenses Certification - Estate (Attachment 2)
Form and Instruction 10 Unreimbursed Medical Expenses Certification (Attach 2)
Countermeasures Injury Compensation Program Request Package Modified 100 1100 0 Form and Instruction 1 Request for Benefits Form and Supporting Documentation
Total burden requested under this ICR: 260 1327 0  
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