OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Category III - Pain/Other Symptoms/Impairment Information

IC 181780 under ICR 202402-0960-002 · OMB 0960-0555.

Documents and Forms
Document Name
Document Type
Form
Form
Other-CE- Arterial Doopler Evaluatio
Other-CE- Arterial Doopler Evaluatio
Other-CE-Fibromyalgia Evaluation She
Other-CE-Fibromyalgia Evaluation She
Other-CE_ Range of Motion Chart
Other-CE_ Range of Motion Chart
Other-CE- Resting Doopler Evaluation
Other-CE- Resting Doopler Evaluation
Other-Third Party Request with Seizu
Other-Third Party Request with Seizu
Form
Form
Form
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Category III - Pain/Other Symptoms/Impairment Information
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
20 CFR 416.912 20 CFR 404.1512

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form Pain Questionnaire Pain Questionnaire Category III - Pain, Other Symptoms, Impairment Information - Revised.pdf No   Paper Only
Form N/A Muscle Examination CE - Muscle Examination.pdf Yes Yes Fillable Fileable
Other-CE- Arterial Doopler Evaluation With Toe CE - Arterial Doppler Evaluation With Toe.pdf No   Paper Only
Other-CE-Fibromyalgia Evaluation Sheet CE - Fibromyalgia Evaluation Sheet.pdf No   Paper Only
Other-CE_ Range of Motion Chart CE - Range of Motion Chart.pdf No   Paper Only
Other-CE- Resting Doopler Evaluation CE - Resting Doppler Evaluation.pdf No   Paper Only
Other-Third Party Request with Seizure Witness Questionnaire Third Party Request with Seizure Witness Questionnaire.pdf No   Paper Only

Income Security General Retirement and Disability

 

2,100,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,100,000 0 0 0 0 2,100,000
Annual IC Time Burden (Hours) 700,000 0 0 0 0 700,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Category III - Pain, Other Symptoms, Impairment Information - Current Category III - Pain, Other Symptoms, Impairment Information - Current.pdf 12/04/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.