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4.3 Certification of Survivor Relationship to Deceased Injur
Countermeasures Injury Compensation Program (CICP)
Death Benefit Certification of Relationship Survivor
Benefits Package and Supporting Documentation
OMB: 0915-0334
OMB.report
HHS/HSA
OMB 0915-0334
ICR 202303-0915-005
IC 208418
4.3 Certification of Survivor Relationship to Deceased Injur
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0334 can be found here:
2024-01-09 - No material or nonsubstantive change to a currently approved collection
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