4. Attachment C Data Collection Form.pdf
PDF 225 KB Posted
- Attached to
- Parent BPAs: CICP Life Care Planner FY25-30
- Solicitation number
- 75R60225Q00179
About this file
This document is a Data Collection Form for the Countermeasures Injury Compensation System (CICP) Life Care Planner with Parent BPAs for Fiscal Years 2025-2030. The form requires detailed personal and professional information from potential participants, including name, Social Security Number, date of birth, medical specialty, taxpayer identification number, and contact details.
The form instructs participants to complete all fields clearly and indicates that case documents will be transmitted via a secure mail system called SEFT, with paper files only sent in very limited circumstances. Additional requirements include providing contact telephone numbers and confirming registration status in the System for Award Management (SAM). The form is designed to collect comprehensive identifying information for potential life care planners participating in the CICP program.
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Text version
Attachment C - Data Collection Form
COUNTERMEASURES INJURY COMPENSATION SYSTEM (CICP)
Parent BPAs: CICP Life Care Planner FY25-30
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.
Name: ____________________________________ SSN: ____________________________________
DOB: ____________________________________ Medical Specialty: ___________________________
Taxpayer Identification Number (If different from SSN):
Unique Entity ID Number: ____________________________________________
Registered in SAM: Yes / No
If yes, SAM Expiration Date: _____________________
Mailing Address:
E: Mail Address: _______________________________
Telephone Number(s):
Office: ____________________ Home: ____________________ Cell: ____________________
File details come from the government source that posted it. Updated .