Information Collection

Category III - Pain/Other Symptoms/Impairment Information

IC 181780 under ICR 201103-0960-011 · OMB 0960-0555.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0555 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information	Form
Pain Questionnaire Pain Questionnaire Pain-OS-Impairment Ques.pdf	Form
Pain.pdf Pain Questionnaire Current Version	IC Document

IC Title:

Category III - Pain/Other Symptoms/Impairment Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

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	Pain Questionnaire	Pain Questionnaire	Pain-OS-Impairment Ques.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: 2,500,000

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	2,500,000	1,500,000	1,000,000
Annual IC Time Burden (Hours)	625,000	375,000	250,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pain Questionnaire Current Version	Pain.pdf	05/19/2011

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