Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Additional Documentation and Certification Modified 30 23 0 Form 3 Certification Form
Authorization for Use or Disclosure of Health Information Form Modified 100 200 0 Form and Instruction 2 CICP Authorization Form
Benefits Package and Supporting Documentation Modified 30 4 0 Instruction
Instruction
Instruction
Form 4.1 Certification of Status for Death Benefit – Alternate Calculation
Form 4.2 Certification of Status for Death Benefit - Standard Calculation
Form 4.3 Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient
Form 4.4 Certification of Status for Administrators of the Estate: Lost Employment Income
Form 4.5 Certification of Status: Lost Employment Income
Form 4.6 Certification of Status: Unreimbursed Medical Expenses
Countermeasures Injury Compensation Program Request Package Modified 100 1100 0 Form 1 CICP Request Form
Form and Instruction 1A CICP Request Form Instructions
Total burden requested under this ICR: 260 1327 0  
To view an IC, click on IC Title