Attachment D - Data Collection Form
Updated
A PDF document (112 KB) attached to Medical Case Reviewer Services for the Vaccine Injury Compensation Program (VICP)/ Countermeasures Injury Compensation Program (CICP)., from the Health Resources and Services Administration. Due Aug 20, 2031, 5:00 PM (UTC-4).
File name: 5. Attachment D - Data Collection Form.pdf
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Description of Agreement - Attachment D
VACCINE INJURY COMPENSATION PROGRAM (VICP)
MEDICAL EXPERT PANEL (MEP)
Data Collection Form
General Instructions:
1. Type or print ALL information clearly, including Not Applicable (N/A) blanks. 2. We are requiring everyone to receive case documents via a secure mail system called SEFT. We will only send paper files on a very limited basis.
3. Please provide a telephone number or numbers where you prefer to be contacted. Taxpayer Identification Number (If different from SSN): Registered in SAM: Yes / No
Mailing Address:
Telephone Number(s):
The beginning of the document. Download the full file to read on.