View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Countermeasures Injury Compensation Program Request Package
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 1 CICP Request Form 03132023 - CICP Request Form - OMB 0915-0334.pdf Yes Yes Fillable Fileable
Form and Instruction 1A CICP Request Form Instructions 03132023 - CICP Request Form Instructions - OMB 0915-0334.PDF Yes Yes Fillable Fileable
Form and Instruction 1 CICP Request Form (with Color) in Spanish - Redline 10112023 - (21) CICP Request Form (with color) 2020 in Spanish - REDLINE.docx Yes Yes Fillable Fileable
Form and Instruction 1 CICP Request Form Instructions in Spanish - Redline 10112023 - (22) CICP Request Form Instructions in Spanish - REDLINE.docx Yes Yes Fillable Fileable

Health Consumer Health and Safety

CICP System of Records Notice   84 FR 28829

100 0
   
Individuals or Households
 
   80 %

  Approved 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 100 0 0 0 0 100
Annual IC Time Burden (Hours) 1,100 0 0 0 0 1,100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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