Information Collection Request

Disability Case Development Information Collections

ICR 202402-0960-002 · OMB 0960-0555 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0960-0555 can be found here:

2024-12-12 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information Form	Unchanged
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information Form	Unchanged
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Form and Instruction	Unchanged
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Form and Instruction	Unchanged
Justification for Non-Substantive Changes - 0960-0555.docx Justification for No Material/Nonsubstantive Change	2024-02-14
Justification for Non-Substantive Changes - 0960-0555.docx Justification for No Material/Nonsubstantive Change	2024-02-14
Supporting Statement - 0555 (Clean Copy).docx Supporting Statement A	2023-04-04
Supporting Statement - 0555 (Clean Copy).docx Supporting Statement A	2023-04-04

IC Document Collections

IC ID	Document Title	Status
9480	Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category) Other-Samples of DDS CE Forms	Unchanged
241087	Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category) Other- THCE Agreeement Call Script - Adult (revised).	Modified
181780	Category III - Pain/Other Symptoms/Impairment Information Form	Unchanged
181780	Category III - Pain/Other Symptoms/Impairment Information Form	Unchanged
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Form and Instruction	Unchanged
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Form and Instruction	Unchanged
179022	Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category) Other-ERE Transmission of "MER Samples" Category	Unchanged
179020	Category II - MER Paper Submissions (subset of "MER Samples") category Other-Sample of MER forms	Unchanged
179019	Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category) Other-Sample of state DDS Claimant Report Letter/Form	Unchanged
179018	Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category) Other-Sample of Appointment Letter Included	Unchanged
179017	Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category) Other-Sample of types of information sent through ERE; electroni	Unchanged

ICR Details

Status	Active
Agency/Subagency	SSA
OMB Control No	0960-0555
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202008-0960-021
Date Submitted to OIRA	2024-02-14
Requested Expiration Date	1969-12-31