Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Additional Documentation and Certification Modified 30 23 0 Form F FORM Attachment F - Additional Documentation Form 2-27-20.pdf
Authorization for Use or Disclosure of Health Information Form Modified 100 200 0 Instruction
Form E Attachment E Authorization for Use or Disclosure of Health Information Form
Benefits Package and Supporting Documentation Modified 30 4 0 Instruction
Instruction
Instruction
Form and Instruction 1 Certification of Status for Death Benefit - Alternative Calculation.docx
Form and Instruction 2 Certification of Status for Death Benefit - Standard Calculation.docx
Form and Instruction 3 Death Benefit Certification of Relationship Survivor.docx
Form and Instruction 4 Lost Employment Income Certification - Estate.docx
Form and Instruction 5 Lost Employment Income Certification.docx
Form and Instruction 6 Unreimbursed Medical Expenses Certification.docx
Countermeasures Injury Compensation Program Request Package Modified 100 1100 0 Form and Instruction D Attachment D Request for Benefits Form
Total burden requested under this ICR: 260 1327 0  
To view an IC, click on IC Title