Information Collection

Pain Report - Child

IC 9452 under ICR 201509-0960-004 · OMB 0960-0540.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0540 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3371-BK Pain Report - Child Form
Revised PA and PRA Statements.pdf Other-Revised Privacy Act and Paperw
SSA-3371-BK Pain Report-Child SSA-3371-BK (revised).pdf Form
SSA-3371-BK (current).pdf Current SSA-3371 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pain Report - Child	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 404.512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3371-BK	Pain Report-Child	SSA-3371-BK (revised).pdf		No		Paper Only
Other-Revised Privacy Act and Paperwork Reduction Act Statements			Revised PA and PRA Statements.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: 250,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	250,000	250,000
Annual IC Time Burden (Hours)	62,500	62,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3371	SSA-3371-BK (current).pdf	09/17/2015

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