Form Pain Questionnaire Pain Questionnaire Pain Questionnaire

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number for this
collection is 0960-0555. We estimate that it will take between 5 to 30 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

PRIVACY ACT STATEMENT
Collection and Use of Information by the Social Security Administration
The Privacy Act of 1974 (5 U.S.C. § 552a) requires us to provide certain facts to each person from whom we
request and collect information in order to administer our programs. These facts include:
• the statutory authority for the request;
• why we need the information;
• whether it is voluntary or mandatory for you to give us the information and the effects, if any, of not
giving us the information; and
• the uses we may make of the information you give us.
The following sections explain our collection, use, and disclosure of the information you give us. If you have
any questions about your rights and responsibilities under the Privacy Act, you may contact any local Social
Security office.
Our authority to collect information
Our specific authority to collect information is found
in sections 205(a), 702, 1631(e)(1)(A) and (B),
1631(f), 1872, and 1875 of the Social Security Act
(the Act), as amended. Additional authority is in
part B of the Federal Coal Mine Health and Safety
Act of 1969.

information to another agency or person without
your written consent. We make these disclosures
for the following reasons:
•
•
•

Why we need the information
We collect information from you in order to
administer our programs. Specifically, the
information we request enables us to:
•
•
•
•
•

assign Social Security numbers;
establish and maintain earnings records;
determine entitlement of applicants and
their families to insurance coverage and or
benefit payments;
issue payments in the right amount for the
right months to people entitled to them; and
conduct program-oriented research in areas
of income distribution and maintenance.

Is providing information voluntary or
mandatory?
It is not mandatory for you to give us the
information we request except in certain instances
explained below. It is usually to your advantage to
comply with our request for information. Failure to
do so, however, could prevent an accurate and
timely decision on a claim you file or result in the
loss of some benefit or service.
Our use(s) of the information you give us
We use the information you give us to administer
our programs. Sometimes we must disclose the

•

to enable a third party or agency to assist us
in establishing your right to benefits or
coverage;
to comply with Federal laws;
to make eligibility determinations in similar
Federal, State, and local health and income
maintenance programs;
to facilitate statistical research, audit, or
investigative activities necessary to assure
the integrity of our programs.

We may also use the information you give us when
we match records by computer. Computer
matching programs compare our records with those
of other Federal, State, or local government
agencies. We use the information from these
matching programs to establish or verify a person’s
eligibility for Federally-funded or administered
benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses of the information
you give us is available in our Privacy Act Systems
of Records Notices. For example, the application
for benefits and supporting documentation of the
factors of entitlement and continuing eligibility is
contained in our Claims Folder System (60-0089);
medical information, doctors’ reports, and State
disability determinations related to a disability claim
is contained in our National Disability Determination
Services File System (60-0044). Additional
information regarding this form, routine uses of
information, and other Social Security programs is
available from our Internet website at
www.socialsecurity.gov or at your local Social
Security office.
Form SSA-5000 (05-2011)