Information Collection

OS Participants

IC 7310 under ICR 201005-0925-001 · OMB 0925-0414.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0414 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 33 Medical History Update OS Participants	Form
Form 2 F151 Activities of Daily Living OS Participants	Form
Form 3 F80 Physical Measurements OS Participants	Form
Form 4 Functional Status OS Participants	Form
Form 4 F100 Blood Collection OS Participants	Form
Form 6 F153 Meds OS Participants	Form
Form 7 F154 Breast CA meds OS Participants	Form
Form 8 F155 Lifestyle OS Participants	Form
1 33 Medical History Update F33 Med Hist Updt.pdf	Form
2 F151 Activities of Daily Living F151 ADL (2).pdf	Form
3 F80 Physical Measurements F80 Phys Meas.pdf	Form
4 Functional Status F90 Func Status.pdf	Form
4 F100 Blood Collection F100 Blood Collect.pdf	Form
6 F153 Meds F153 Meds.pdf	Form
7 F154 Breast CA meds F154 Breast CA meds.pdf	Form
8 F155 Lifestyle F155 Lifestyle.pdf	Form
SSB_Attachment 2_OS Adjudicator Forms List.pdf SSB_Attachment 2_OS Adjudicator Forms List	IC Document
SSA_Attachment 1_OS Data Collection Instrument List.pdf SSA_Attachment 1_OS Data Collection Instrument List	IC Document
SSB_Attachment 3_Sample participant newsletter.pdf SSB_Attachment 3_Sample participant newsletter	IC Document

IC Title:

OS Participants

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	33 Medical History Update	F33 Med Hist Updt.pdf	Yes	Yes	Paper Only
Form	2	F151 Activities of Daily Living	F151 ADL (2).pdf	Yes	Yes	Paper Only
Form	3	F80 Physical Measurements	F80 Phys Meas.pdf	Yes	Yes	Paper Only
Form	4	Functional Status	F90 Func Status.pdf	Yes	Yes	Paper Only
Form	4	F100 Blood Collection	F100 Blood Collect.pdf	Yes	Yes	Paper Only
Form	6	F153 Meds	F153 Meds.pdf	Yes	Yes	Paper Only
Form	7	F154 Breast CA meds	F154 Breast CA meds.pdf	Yes	Yes	Paper Only
Form	8	F155 Lifestyle	F155 Lifestyle.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42,500

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	47,600	-21,953	69,553
Annual IC Time Burden (Hours)	19,801	-3,708	23,509
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSB_Attachment 2_OS Adjudicator Forms List	SSB_Attachment 2_OS Adjudicator Forms List.pdf	03/31/2010
SSA_Attachment 1_OS Data Collection Instrument List	SSA_Attachment 1_OS Data Collection Instrument List.pdf	03/31/2010
SSB_Attachment 3_Sample participant newsletter	SSB_Attachment 3_Sample participant newsletter.pdf	03/31/2010

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