Information Collection

Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment

IC 9288 under ICR 200701-0960-005 · OMB 0960-0431.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4734-BK Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment	Form
SSA-4734-BK Physical Residual Functional Capacity Assessment SSA-4737-BK.pdf	Form
SSA-4734-F4-SUP Mental Residual Functional Capacity Assessment SSA-4734-F4-SUP.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 416.945-.946 20 CFR 404.1545-.1546

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-4734-BK	Physical Residual Functional Capacity Assessment	SSA-4737-BK.pdf		No		Paper Only
Form	SSA-4734-F4-SUP	Mental Residual Functional Capacity Assessment	SSA-4734-F4-SUP.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,397,646

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,397,646	-24,219	2,421,865
Annual IC Time Burden (Hours)	799,215	-8,073	807,288
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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