MEDICAL HISTORY AND DISABILITY REPORT

ICR 199407-0960-004

OMB: 0960-0504

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
115685 Migrated
ICR Details
0960-0504 199407-0960-004
Historical Active 199403-0960-007
SSA
MEDICAL HISTORY AND DISABILITY REPORT
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 08/23/1994
Retrieve Notice of Action (NOA) 07/07/1994
This information collection is approved through 9-95 at which time SSA plans to have a new revised form SSA 3820 ready for national implement tion. SSA must receive OMB approval for use of the revised form. If unable to begin implementation by 9-95, SSA should provide an explaination for the delay.
  Inventory as of this Action Requested Previously Approved
09/30/1995 09/30/1995
453,000 0 0
151,000 0 0
0 0 0

THE INFORMATION OBTAINED BY FORM SSA-3820 IS USED BY THE SOCIAL SECURITY ADMINISTRATION TO HELP MAKE A DETERMINATION IN CLAIMS FOR DISABLED CHILDREN. THE RESPONDENTS ARE CLAIMANTS FOR THOSE BENEFITS WHO MAY BE ENTITLED BECAUSE OF ALLEGED DISABILITIES.

None
None


No

1
IC Title Form No. Form Name
MEDICAL HISTORY AND DISABILITY REPORT SSA-3820

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 453,000 0 0 453,000 0 0
Annual Time Burden (Hours) 151,000 0 0 151,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/07/1994


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