OMB control number
Countermeasures Injury Compensation Program (CICP)
OMB 0915-0334 · HHS/HSA.
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.
The latest form for Countermeasures Injury Compensation Program (CICP) expires 2026-04-30 and can be found here.
Benefits Package and Supporting Documentation Countermeasures Injury Compensation Program Request Package
Federal Enterprise Architecture: Health - Consumer Health and Safety
| Form 1A | CICP Request Form Instructions | Fillable Fileable | Form and instruction |
| Form 1 | CICP Request Form Instructions in Spanish - Redline | Fillable Fileable | Form and instruction |
| Form 1 | CICP Request Form (with Color) in Spanish - Redline | Fillable Fileable | Form and instruction |
| Form 1 | CICP Request Form | Fillable Fileable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.