Disability Report--Appeal (EDCS)

Disability Report-Appeal

EDCS 3441 Screenshots - Revised Version

Disability Report--Appeal (EDCS)

OMB: 0960-0144

Document [pdf]
Download: pdf | pdf
EDCS 3441 Screenshots (as of 4/25/2018)

3441 About You

Page 1 of 7

3441 Contacts

Page 2 of 7

Commented [KB1]: Add “previously described.” The
sentence should read:
“Since you last told us about your medical conditions, has
there been any CHANGE (for better or worse) in your
previously described physical or mental conditions.”

3441 Medical Conditons
Commented [KB2]: Add “or updated.” The sentence
should read:
“Tell us who may have NEW OR UPDATED medical records
about any of your physical or mental conditions (including
emotional or learning problems)…”

3441 Medical Sources

Page 3 of 7

3441 Tests

3441 Other Medical Information

Page 4 of 7

3441 Medicines
Commented [KB3]: Add “previously described.” The
sentence should read:
“Since you last told us about your activities, has there been
any change (for better or worse) in your previously
described daily activities due to your physical or mental
conditions?”

3441 Activities

Page 5 of 7

3441 Work and Education

3441 Voc Rehab

Page 6 of 7

3441 Remarks

Page 7 of 7


File Typeapplication/pdf
AuthorSherrod, Latia A.
File Modified2019-02-01
File Created2018-12-13

© 2024 OMB.report | Privacy Policy