OMB control number

Pain Report - Child

OMB 0960-0540 · SSA.

OMB 0960-0540

SSA requests information on Form SSA-3371-BK to provide disability interviewers, as well as applicants or claimants in self-help situations, with a convenient means to record information about the claimant's pain or other symptoms. The State disability determination services (DDS) adjudicators and administrative law judges then use the information to assess the effects of symptoms on function for purposes of determining disability under the Social Security Act. The respondents are applicants for or claimants of Supplemental Security Income (SSI) benefits.

The latest form for Pain Report - Child expires 2026-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-3371-BK Pain Report - Child Form
Addendum - 0540.docx Supplementary Document
Supporting Statement - 0540 (Final).docx Supporting Statement A
Pain Report - Child Form

All Historical Document Collections

202112-0960-006 Approved without change	Revision of a currently approved collection	2022-02-25
201810-0960-012 Approved without change	Revision of a currently approved collection	2019-01-25
201509-0960-004 Approved without change	Revision of a currently approved collection	2015-11-27
201210-0960-003 Approved without change	Revision of a currently approved collection	2013-01-15
200911-0960-001 Approved without change	Revision of a currently approved collection	2010-02-05
200612-0960-007 Approved without change	Extension without change of a currently approved collection	2007-02-26
200403-0960-008 Approved without change	Extension without change of a currently approved collection	2004-03-12
200104-0960-006 Approved without change	Extension without change of a currently approved collection	2001-04-23
199802-0960-009 Approved without change	Extension without change of a currently approved collection	1998-02-24
199410-0960-002 Approved without change	New collection (Request for a new OMB Control Number)	1994-10-05