Information Collection

Category III - Pain/Other Symptoms/Impairment Information

IC 181780 under ICR 201201-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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: Unchanged

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	Previously Approved
Annual Number of Responses for this IC	2,500,000	2,500,000
Annual IC Time Burden (Hours)	625,000	625,000
Annual IC Cost Burden (Dollars)	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.