Information Collection

HA-66 with Medical Source Information - electronic submission

IC 195758 under ICR 201009-0960-004 · OMB 0960-0722.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0722 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HA-66 & HA-67 Electronic Screen.pdf	Other-Internet Screen

IC Title:

HA-66 with Medical Source Information - electronic submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Other-Internet Screen			HA-66 & HA-67 Electronic Screen.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,940

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	196,680	196,680
Annual IC Time Burden (Hours)	49,170	49,170
Annual IC Cost Burden (Dollars)	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.