Information Collection

Pain Report - Child

IC 9452 under ICR 201810-0960-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3371-BK Pain Report - Child	Form
Prvacy Act Statement 090-0540 (revised).docx	Other-Privacy Act Statement (revised
SSA-3371-BK Pain Report-Child SSA-3371-BK (revised).pdf	Form
SSA-3371-BK (current version).pdf Current SSA-3371	IC Document

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 404.512 20 CFR 416.912

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	SSA-3371-BK	Pain Report-Child	SSA-3371-BK (revised).pdf		No		Paper Only
Other-Privacy Act Statement (revised) 0540			Prvacy Act Statement 090-0540 (revised).docx		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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3371	SSA-3371-BK (current version).pdf	01/25/2019

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