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Federal forms, ICRs, and supporting documents

Information Collection

Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)

IC 9480 under ICR 202412-0960-005 · OMB 0960-0555.

Documents and Forms
Document Name
Document Type
Other-Samples of DDS CE Forms
Other-Samples of DDS CE Forms
Other-Claimant Request with Cardiac
Other-Claimant Request with Cardiac
Other-Claimant Request with Fatigue
Other-Claimant Request with Fatigue
Other-Claimant Request with Headache
Other-Claimant Request with Headache
Other-Claimant Request with Pain Que
Other-Claimant Request with Pain Que
Other-Claimant Request with Seizure
Other-Claimant Request with Seizure
Other-Claimant Request with Vision Q
Other-Claimant Request with Vision Q
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)
 
No Unchanged
 
Voluntary
 
20 CFR 416.919 20 CFR 404.1513 20 CFR 416.918(c) 20 CFR 416.917 20 CFR 404.1514 20 CFR 404.1512 20 CFR 416.1013 20 CFR 416.914 20 CFR 404.1518(c) 20 CFR 404.1503a 20 CFR 404.1517 20 CFR 404.1613 20 CFR 404.1519 20 CFR 404.1614 20 CFR 404.1624 20 CFR 404.1024 20 CFR 416.1014 20 CFR 416.903a 20 CFR 416.912 20 CFR 416.913

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Samples of DDS CE Forms Category I - CE a) Credentialing - Revised.pdf No   Paper Only
Other-Claimant Request with Cardiac Questionnaire Claimant Request with Cardiac Questionnaire.pdf No   Paper Only
Other-Claimant Request with Fatigue Questionnaire Claimant Request with Fatigue Questionnaire.pdf No   Paper Only
Other-Claimant Request with Headache Questionnaire Claimant Request with Headache Questionnaire.pdf No   Paper Only
Other-Claimant Request with Pain Questionnaire Claimant Request with Pain Questionnaire.pdf No   Paper Only
Other-Claimant Request with Seizure Questionnaire Claimant Request with Seizure Questionnaire.pdf No   Paper Only
Other-Claimant Request with Vision Questionnaire Claimant Request with Vision Questionnaire.pdf No   Paper Only

Income Security General Retirement and Disability

 

1,400,000 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 1,400,000 0 0 0 0 1,400,000
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 I - CE a) Paper Submissions Samples - Current Category I - CE a) Paper Submissions Samples - Current.pdf 12/04/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.