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Form No CICP-1 OMB Control Number 0915-0334 Expiration Date 9/30/2013 COUNTERMEASURES INJURY COMPENSATION PROGRAM REQUEST FOR BENEFITS FORM The Countermeasures Injury Compensation Program CICP provides certain medical and lost employment income benefits for individuals who were administered or used a covered countermeasure such as 2009 H1N1 vaccine and peramivir mechanical ventilator N-95 Filter Mask anthrax vaccine smallpox vacci...

How to fill out countermeasures injury compensation program

How to fill out countermeasures injury compensation program:

1. Obtain the necessary forms from the appropriate authority or organization handling the program.
2. Carefully read the instructions provided with the forms to understand the requirements and process.
3. Provide accurate and detailed information about the injury, including the date, location, cause, and circumstances surrounding it.
4. Include any supporting documentation such as medical records, incident reports, witness statements, or photos.
5. Fill out all required personal information correctly, including name, address, contact details, and any applicable identification or insurance numbers.
6. Clearly and concisely describe the extent and impact of the injury, including any resulting physical or mental limitations.
7. If applicable, provide information about any previous claims or legal actions related to the injury.
8. Review the completed form thoroughly to ensure all sections are filled out accurately and completely.
9. Sign and date the form, and submit it to the designated authority or organization according to their instructions.

Who needs countermeasures injury compensation program:

1. Individuals who have suffered injuries as a result of countermeasures taken during an emergency or crisis situation.
2. This may include first responders, emergency personnel, or civilians affected by containment measures or preventive actions.
3. The program is designed to provide financial assistance or compensation to those who have suffered injuries or incurred medical expenses due to these countermeasures.

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What is countermeasures injury compensation program?

The Countermeasures Injury Compensation Program provides compensation to individuals who suffer serious physical injury or death as a direct result of the administration of a covered countermeasure, which is a vaccine, medication, device, or other item used to prevent or treat a disease or condition.

Who is required to file countermeasures injury compensation program?

Individuals who have suffered serious physical injury or death as a direct result of a covered countermeasure are required to file a claim under the Countermeasures Injury Compensation Program.

How to fill out countermeasures injury compensation program?

To fill out the Countermeasures Injury Compensation Program, individuals should provide detailed information about the injury or death, the countermeasure involved, and any supporting documentation such as medical records.

What is the purpose of countermeasures injury compensation program?

The purpose of the Countermeasures Injury Compensation Program is to provide financial support to individuals who have been injured by covered countermeasures in order to mitigate the potential negative consequences of such injuries.

What information must be reported on countermeasures injury compensation program?

The Countermeasures Injury Compensation Program requires information such as the details of the injury or death, the countermeasure involved, medical records, and any other supporting documentation.