Request
Form
OMB
No 0915-0282
Expiration Date: 05-31-2004
This
Request Form is to be used by injured smallpox vaccine
recipients or vaccinia contacts, their survivors,
their estates, or their representatives who are seeking
the payment of benefits from the Smallpox Vaccine
Injury Compensation (SVIC) Program under the Smallpox
Emergency Personnel Protection Act of 2003. Refer
to the instructions and the documentation checklist
for the supporting documentation that you must provide
in order to be deemed eligible for payment. The Request
Form and supporting documentation are subject to audit
by the U.S. Department of Health and Human Services’
Office of Inspector General, the U.S. Department of
Justice, the U.S. Department of Labor, and/or the
General Accounting Office.
Refer
to the Request Form Instructions. All terms, such
as “smallpox vaccine recipient,” “vaccinia contact,”
and “covered injury,” are described in the instructions
as well as the procedures for a requester to submit
a Request Package to the SVIC Program.
Benefits
Sought
-
To be completed by all individuals who submit a
Request Form.
Injured individuals or their estates may be eligible
for medical benefits, lost employment income benefits
or both. Survivors are eligible for death benefits
only. Check all that apply:
[ ] Medical benefits
[ ] Lost employment income benefits
[ ] Death benefits
Section
A. Smallpox Vaccine Recipient or Vaccinia Contact
Who Sustained an Injury
Refer to the instructions
for Section A.
-
If you are a smallpox vaccine recipient,
or the survivor, representative, or representative
of the estate of one, complete section
A1.
- If
you are a vaccinia contact, or the survivor, representative,
or representative of the estate of one,
complete section A2.
A1.
THIS SECTION DESCRIBES THE INJURED SMALLPOX VACCINE
RECIPIENT
Name:
Social
Security Number: |
Date
of Birth: |
Type
of injury from the vaccination or other covered countermeasure:
The
number of days of lost employment income that resulted
from the medical injury:
Check
here [ ] if the smallpox vaccine recipient had a dependent
under the age of 18 at the date of the onset of the
medical injury.
If
the smallpox vaccine recipient is no longer living,
provide date of death:
Complete
address information if smallpox vaccine recipient
is living:
Address:
Daytime
telephone number(s):
A2.
THIS SECTION DESCRIBES THE INJURED VACCINIA CONTACT
Name:
Social
Security Number: |
Date
of Birth: |
Type
of injury from the vaccinia:
Date
of first symptom of the medical injury:
The
number of days of lost employment income that resulted
from the medical injury:
Check
here [ ] if the vaccinia contact had a dependent under
the age of 18 at the date of the onset of the medical
injury.
If
the vaccinia contact is no longer living, provide
date of death:
Complete
address information if the vaccinia contact is living:
Address:
Daytime
telephone number(s):
SOURCE
OF EXPOSURE TO VACCINIA
Check
one of the boxes below and provide the appropriate
information:
-
Check here [ ] If the individual contracted vaccinia
from a smallpox vaccine recipient, then provide
the name of that smallpox vaccine recipient ________________________;
or
-
Check here [ ] if the individual contracted vaccinia
from another contact; then provide the name of that
contact: ____________________________ and the name
of the smallpox vaccine recipient from whom that
contact contracted vaccinia: _____________________________;
or
- Check
here [ ] if the identity of the person from whom
the individual contracted vaccinia is unknown. Attach
a narrative explaining why this information cannot
be provided and the circumstance surrounding the
accidental vaccinia exposure (that led to the contracting
of vaccinia).
SECTION
B. SURVIVOR(S) OF A SMALLPOX VACCINE RECIPIENT OR
A VACCINIA CONTACT
Refer to the instructions for Section B.
Name:
Social
Security Number: |
Date
of Birth: |
Address:
Daytime
telephone number(s):
Check
the box that describes the Survivor’s Relationship
to the Individual in Section A
[
] Spouse
[ ] Eligible Child (described in the instructions)
[ ] Dependent younger than the age of 18
[ ] Beneficiary in most recently executed life insurance
policy (and there are no survivors in the categories
described above)
[ ] Parent (and there are no survivors in the categories
described above)
[ ] Legal Guardian of a deceased minor (and there
are no survivors in the categories listed above)
Check
the box that indicates if the survivor is a sole survivor
or if there are other survivors who may be eligible
for benefits payment
[ ] To the best of my knowledge, there are no other
survivors who may be eligible for payment under
the Act.
[ ] There are other survivors who may be eligible
for benefits payment under the Act. I am providing
all of their names and their relationship to the
person we survived. (If this box is checked, list
survivors. Use additional sheet, if necessary. Eligible
survivors are described above).
Name: |
Name: |
Relationship: |
Relationship: |
Name: |
Name: |
Relationship: |
Relationship: |
[
] Check this box if this is a Request Form filed on
behalf of multiple survivors and submit with the Request
Form the names, addresses, Social Security Numbers,
and daytime telephone numbers of all the survivors
to be included in this Request Form.
SECTION
C. REPRESENTATIVE(S) OF THE ESTATE OF A SMALLPOX VACCINE
RECIPIENT OR A VACCINIA CONTACT
Refer to the instructions for Section C.
Name:
Address:
Daytime
telephone number(s):
SECTION D. PERSONAL REPRESENTATIVE
Complete this section if you are the attorney or other
representative for the requester. If this section
is completed, all communications will be made only
to the personal representative. Refer to the instructions
for Section D.
Name:
Address:
Daytime
telephone number(s):
Does
the person you are representing have the legal capacity
to receive payments?
[ ] Yes - or -
[ ] No. (e.g., a minor or an individual who is otherwise
legally incompetent)
If no, please explain:
If
a personal representative seeks a death benefit on
behalf of one or more minor dependents who are also
surviving children, then the legal guardian must select
one of the two payment options below on behalf of
all the dependents for whom he or she is the legal
guardian. Refer to instructions for a description
of the options.
[ ] Death Benefit under the Standard Calculation,
or
[ ] Death Benefit under the Alternative Calculation
SECTION
E. SIGNATURE
To
be signed by the requester. If the requester
does not have the legal capacity to receive payments,
then the Request Form is to be signed by the legal
guardian of the requester.
Refer to the instructions for Section E.
Reminder:
Attach all necessary documentation. See
instructions.
Acknowledgement of Continuing Obligation to
Correct, Amend and Supplement Information, and Certification
of Accuracy of Information
I
hereby acknowledge that the United States will rely
on the information contained in the Request Form,
and the documentation submitted in connection with
the Request Form, and I have a continuing obligation
to correct, amend and/or supplement the information
provided in connection with this Request Form if any
of the material information, which I have submitted,
should change.
I
hereby certify that the information provided in this
Request Form is true and accurate to the best of my
knowledge. Further, I understand that false statements
or claims made in connection with this Request Form,
including subsequent information and documentation
submitted in connection with this Request Form, may
result in fines, imprisonment and/or any other remedy,
including civil remedies, available by law to the
United States.
If
there is a personal representative identified in Section
D, I affirm that I am legally competent and that I
have authorized that person to submit a Request Form
on my behalf.
Name
(type or print clearly):
Submit your Request Form and all the required documentation
to the SVIC Program by U.S. mail, by a private courier
service or commercial carrier to:
Smallpox Vaccine Injury Compensation Program Office
5600 Fishers Lane, Room 11C-06
Rockville, MD 20857
PRIVACY
ACT STATEMENT
Section 2 of Public Law 108-20 and the Debt Collection
Improvement Act of 1996 authorize collection of this
information. It will be used to determine your eligibility
to receive benefits. This information will be disclosed
to the U.S. Department of Health and Human Services
and its consultants; and Federal, State, or local
law enforcement agencies if the Government becomes
aware of a possible violation of civil or criminal
law. Furnishing the information on this form, including
the Social Security Number, is voluntary, but failure
to do so may delay or prevent the receipt of a payment.
The information collected will be maintained confidentially
pursuant to the Privacy Act.
Contact:
smallpox@hrsa.gov
or 1-888-496-0338
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