View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0915-0334
ICR Reference No:
202110-0915-001
Status:
Historical Active
Previous ICR Reference No:
202001-0915-002
Agency/Subagency:
HHS/HSA
Agency Tracking No:
20201
Title:
Countermeasures Injury Compensation Program (CICP)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/29/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/06/2021
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2023
03/31/2023
03/31/2023
Responses
260
0
260
Time Burden (Hours)
1,327
0
1,327
Cost Burden (Dollars)
0
0
0
Abstract:
OMB approval of the information collection requirements for the Countermeasures Injury Compensation Program (CICP or Program). The CICP provides compensation to eligible individuals (requesters) who suffer serious injuries directly caused by a covered countermeasure administered or used pursuant to a PREP Act Declaration, or to their estates and/or survivors. The CICP requires the Request for Benefits Package, which includes the Request for Benefits Form and Authorization for Use or Disclosure of Health Information Form(s), as well as the injured countermeasure recipient’s medical records and supporting documentation to determine whether a requester is eligible for Program benefits (compensation) for their injury and if applicable, to calculate the amount of program benefits a requester is eligible for.
Authorizing Statute(s):
US Code:
42 USC 247d-6d
Name of Law: Public Readiness and Emergency Preparedness Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
84 FR 33954
07/16/2019
30-day Notice:
Federal Register Citation:
Citation Date:
85 FR 322
01/03/2020
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
4
IC Title
Form No.
Form Name
Additional Documentation and Certification
F
FORM Attachment F - Additional Documentation Form 2-27-20.pdf
Authorization for Use or Disclosure of Health Information Form
E, E - Spanish
Attachment E Authorization for Use or Disclosure of Health Information Form
,
CICP Authorization Form 2020 SPANISH
Benefits Package and Supporting Documentation
4, 2, 1, 3, 6, 5
Certification of Status for Death Benefit - Alternative Calculation.docx
,
Certification of Status for Death Benefit - Standard Calculation.docx
,
Death Benefit Certification of Relationship Survivor.docx
,
Lost Employment Income Certification - Estate.docx
,
Lost Employment Income Certification.docx
,
Unreimbursed Medical Expenses Certification.docx
Countermeasures Injury Compensation Program Request Package
D, D - Spanish
Attachment D Request for Benefits Form
,
Final CICP Request Form (with color)_SPANISH.pdf
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
260
260
0
0
0
0
Annual Time Burden (Hours)
1,327
1,327
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$41,355
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Elyana Bowman 301 443-3983 enadjem@hrsa.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
10/06/2021
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