5. Attachment D - Data Collection Form.pdf
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- Solicitation number
- 75R60225Q00181
About this file
This document is a Data Collection Form for the Vaccine Injury Compensation Program (VICP) Medical Expert Panel (MEP). The form requires detailed personal and professional information from medical experts, including name, Social Security Number, date of birth, medical specialty, taxpayer identification number, and contact details. Additional administrative requirements include registering in the System for Award Management (SAM) and using a secure mail system called SEFT for receiving case documents. The form is designed to collect comprehensive contact and identification information from medical professionals who will serve on the VICP Medical Expert Panel, with specific instructions to complete all fields clearly and provide preferred contact methods.
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Text version
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.
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 .