Physical Residual Functional Capacity Assessment; Mental Residual Functional Capacity Assessment

ICR 200104-0960-004

OMB: 0960-0431

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0960-0431 200104-0960-004
Historical Active 200004-0960-004
SSA
Physical Residual Functional Capacity Assessment; Mental Residual Functional Capacity Assessment
Revision of a currently approved collection   No
Regular
Approved without change 05/29/2001
Retrieve Notice of Action (NOA) 04/20/2001
  Inventory as of this Action Requested Previously Approved
05/31/2004 05/31/2004 06/30/2003
1,130,772 0 1,130,772
376,924 0 376,924
0 0 0

The information collected on form SSA-434-BK is needed by SSA to assist in the adjudication of disability claims involving physical and/or mental impairments. The form assists the State DDS to evaluate impairment(s) by providing a standardized data collection format to present findings in a clear, concise and consistent manner. The respondents are State DDSs administering title II and title XVI disability programs.

None
None


No

1
IC Title Form No. Form Name
Physical Residual Functional Capacity Assessment; Mental Residual Functional Capacity Assessment SSA-4734-BK, SSA-4734-F4-SUP

  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 1,130,772 1,130,772 0 0 0 0
Annual Time Burden (Hours) 376,924 376,924 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
04/20/2001


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