Medical Report (Individual with Childhood Impairment)

ICR 200112-0960-005

OMB: 0960-0102

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
9058 Migrated
ICR Details
0960-0102 200112-0960-005
Historical Active 199811-0960-002
SSA
Medical Report (Individual with Childhood Impairment)
Extension without change of a currently approved collection   No
Regular
Approved without change 01/09/2002
Retrieve Notice of Action (NOA) 12/05/2001
Approved. Upon resubmission of this package, the form should be fully compliant with the requirements of GPEA.
  Inventory as of this Action Requested Previously Approved
01/31/2005 01/31/2005 01/31/2002
12,000 0 12,000
6,000 0 6,000
0 0 0

The information on Form SSA-3827-BK is needed to determine the claimant's physical and mental status prior to making a childhood disability determination. The respondents are medical sources.

None
None


No

1
IC Title Form No. Form Name
Medical Report (Individual with Childhood Impairment) SSA-3827

  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 12,000 12,000 0 0 0 0
Annual Time Burden (Hours) 6,000 6,000 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.
12/05/2001


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