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Federal forms, ICRs, and supporting documents

Information Collection

Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)

IC 241087 under ICR 202412-0960-005 · OMB 0960-0555.

Documents and Forms
Document Name
Document Type
Other- THCE Agreeement Call Script -
Other- THCE Agreeement Call Script -
Other- THCE Agreeement Call Script -
Other- THCE Agreeement Call Script -
Other- THCE Agreeement Call Script -
Other- THCE Agreeement Call Script -
Other- THCE Agreement Form - Adult
Other- THCE Agreement Form - Adult
Other- THCE Agreement Form - Adult
Other- THCE Agreement Form - Adult
Other-THCE Agreement Form - Adult wi
Other-THCE Agreement Form - Adult wi
Other- THCE Agreement Form - Child
Other- THCE Agreement Form - Child
Other- DCPS Scheduling Text and Emai
Other- DCPS Scheduling Text and Emai
Other- DCPS Scheduling Text and Emai
Other- DCPS Scheduling Text and Emai
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.912 20 CFR 416.913 20 CFR 416.914 20 CFR 416.917 20 CFR 416.918(c) 20 CFR 416.919 20 CFR 416.903a 20 CFR 416.1013 20 CFR 416.1024 20 CFR 404.1503a 20 CFR 404.1512 20 CFR 404.1513 20 CFR 416.1014 20 CFR 404.1514 20 CFR 404.1517 20 CFR 404.1518(c) 20 CFR 404.1519 20 CFR 404.1614 20 CFR 404.1624 20 CFR 404.1613

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other- THCE Agreeement Call Script - Adult (revised). THCE Agreeement Call Script - Adult (revised).pdf No   Paper Only
Other- THCE Agreeement Call Script - Adult with Legal Guardian THCE Agreeement Call Script - Adult with Legal Guardian (revised).pdf No   Paper Only
Other- THCE Agreeement Call Script - Child (revised) THCE Agreeement Call Script - Child (revised).pdf No   Paper Only
Other- THCE Agreement Form - Adult THCE Agreement Form - Adult (revised).pdf Yes Yes Fillable Fileable
Other- THCE Agreement Form - Adult THCE Agreement Form - Adult (revised).pdf Yes Yes Fillable Fileable
Other-THCE Agreement Form - Adult with Legal Guardian THCE Agreement Form - Adult with Legal Guardian (revised).pdf Yes Yes Fillable Fileable
Other- THCE Agreement Form - Child THCE Agreement Form - Child (revised).pdf Yes Yes Fillable Fileable
Other- DCPS Scheduling Text and Email Consent Script DCPS Scheduling Text and Email Consent Script.pdf Yes No Fillable Printable
Other- DCPS Scheduling Text and Email Consent. DCPS Scheduling Text and Email Consent.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

 

1,175,536 0
   
Individuals or Households
 
   100 %

  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 1,175,536 0 0 1,047,288 0 128,248
Annual IC Time Burden (Hours) 78,369 0 0 67,682 0 10,687
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Telehealth Consultative Examination Agreement Form (current) Telehealth Consultative Examination Agreement Form (current).pdf 12/12/2024
Telehealth Consultative Examination Agreement Call Script (current) Telehealth Consultative Examinaton Agreement Call Script (current).pdf 12/12/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.