Information Collection

Medical History And Disability Report - Widow, Widower, Surviving Divorced Wife, Disabled Child

IC 114910 under ICR 198706-0960-001 · OMB 0960-0147.

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Document Name	Document Type

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IC Title:

MEDICAL HISTORY AND DISABILITY REPORT - WIDOW, WIDOWER, SURVIVING DIVORCED WIFE, DISABLED CHILD

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3820				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 134,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	134,000	134,000
Annual IC Time Burden (Hours)	44,667	44,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.