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:
202401-0915-002
Status:
Active
Previous ICR Reference No:
202303-0915-005
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:
01/10/2024
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/09/2024
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2026
04/30/2026
04/30/2026
Responses
260
0
260
Time Burden (Hours)
1,327
0
1,327
Cost Burden (Dollars)
0
0
0
Abstract:
The Countermeasures Injury Compensation Program (CICP) provides compensation to eligible individuals (requesters) seriously injured by a covered countermeasure administered or used pursuant to a Public Readiness and Emergency Preparedness Act of 2005 (PREP Act) Declaration, or to their estates and/or survivors. The CICP requires the Request for Benefits Package 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 to receive. The Request for Benefits Package 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. A requester who is an injured countermeasure recipient, the requester’s legal representative, or the estate or survivor(s) of an injured countermeasure recipient is responsible for submitting the Request for Benefits Package, as well as the injured countermeasure recipient’s medical records and supporting documentation.
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:
88 FR 358
01/04/2023
30-day Notice:
Federal Register Citation:
Citation Date:
88 FR 17860
03/24/2023
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
1 , 1, 3
Certification Form
,
Certification Form - Clean
,
Certification Form - Redline
Authorization for Use or Disclosure of Health Information Form
2, 1, 1
CICP Authorization Form
,
CICP Authorization Form in Spanish - Redline
,
CICP Authorization Form Instructions in Spanish - Redline
Benefits Package and Supporting Documentation
Attachment 3, Attachment 2 - Estate, Attachment 2 - Estate, Attachment 1 - Survivor, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, Attachment 2, Attachment 2, Attachment 3, Attachment 3 - Estate, Attachment 1 - Survivor, Attachment 2 - Survivor, Attachment 2 - Survivor, Attachment 3 - Survivor
Certification of Status for Death Benefit – Alternate Calculation
,
Certification of Status for Death Benefit - Standard Calculation
,
Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient
,
Certification of Status for Administrators of the Estate: Lost Employment Income
,
Certification of Status: Lost Employment Income
,
Certification of Status: Unreimbursed Medical Expenses
,
Unreimbursed Medical Expenses Certification A (Clean)
,
Unreimbursed Medical Expenses Certification (Redline)
,
Lost Employment Income Certification A (Clean)
,
Lost Income Certification A (Redline)
,
Unreimbrused Medical Expenses Certification (Clean)
,
Unreimbursed Medical Expenses Certification (redline)
,
Lost Income Certification
,
Certifcation of Status for Death Benefit (clean)
,
Certification of Status for Death Benefit - Redline
,
Certification of Status for Death Benefit - Alternative Calculation (Clean)
,
Certification of Status for Death Benefit - Alternative Calculation (redline)
,
Survivor Attachment 3 - Death Benefit Certification of Relationship Redline
Countermeasures Injury Compensation Program Request Package
1A, 1, 1, 1
CICP Request Form
,
CICP Request Form Instructions
,
CICP Request Form (with Color) in Spanish - Redline
,
CICP Request Form Instructions in Spanish - Redline
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:
$46,710
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.
Yes
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:
Laura Cooper 301 443-2126 lcooper@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:
01/09/2024
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