Disability Report--Appeal (Internet Version)

Disability Report-Appeal

i3441 Disability Report Screenshots - Revised Version

Disability Report--Appeal (Internet Version)

OMB: 0960-0144

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A. Section: Entry, Restart, and Exit Pages
1. Wlcm001* – Getting Ready Contains New Language

*This is the screen identifier from SSA’s ApPages documentation for the existing iAppeals Revitalization/Attachment
Utility application.

1

2. New Screen – Terms of Service

2

3

3. New Screen - Return to a Saved Appeal 1st Party (was Rtrn001 - Return to a Saved Appeal)

4. New Screen - Return to a Saved Appeal 3rd Party (was Rtrn001 - Return to a Saved Appeal)

4

5. New Screen – Save and Exit – 1st Party (was Exit 001 – Save and Exit)

5

6. New Screen – Save and Exit – 3rd Party (was Exit 001 – Save and Exit)

6

B. Section: Identification Pages
7. Rtry001-01 – Reentry Number – 1st Party Contains New Language

7

8. Rnty001-3 – Reentry Number - 3rd Party Contains New language

8

9. Frmc001 - Preparer, Identification 3rd Party: Form Completer: Preparer’s Info

9

10. Appd001-1 - Your Information 1st Party: Applicant Information

10

11. Appd001-3 - Applicant Information 3rd Party: Applicant Information

11

12. Rpnp001-1 – Representative – 1st Party Contains New Tab

13. Rpnp001-3 – Representative – 3rd Party Contains New Tab

12

14. Appl001hr-1 Appeal Request 1st Party: Request for Hearing

13

15. Appl001hr-3 Appeal Request 3rd Party: Request for Hearing

14

16. Appl001rec-1 - Appeal Request 1st Party: Request for Reconsideration

15

17. Appl001rec-3 - Appeal Request 3rd Party: Request for Reconsideration

16

18. Cfid001-1 - Who Are You? 1st Party: Confirm Your Identity

19. Cfid001-3 - Who Are You? 3rd Party: Confirm Your Identity

17

20. Cnti001-1 - Someone We Can Contact 1st Party: Contact Information

18

21. Cnti001-3 - Someone We Can Contact 3rd Party: Contact Information

19

C. Section: Medical Pages
1. Cicd001-1 – Medical Conditions – 1st Party Change in Medical Conditions Contains New Language
and new Submit Tab

20

2. Cicd001-3 – Medical Conditions – 3rd Party Change in Medical Conditions Contains New Language
and new Submit Tab

21

3. Nmed001-1 - Medical Treatment 1st Party: Medical Treatment

22

4. Nmed001-3 - Medical Treatment 3rd Party: Medical Treatment

23

5. Doho001-1 – Doctors and Hospitals – 1st Party Contains New Submit Tab

24

6. Doho001-3 – Doctors and Hospitals – 3rd Party Contains New Submit Tab

25

7. Doct002-1 – Doctor or Healthcare Provider Details – 1st Party Contains New Language

26

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8. Doct002-3 – Doctor or Healthcare Provider Details – 3rd Party Contains New Language

28

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9. Hosp002-1 - Hospital or Clinic Details 1st Party: Specific Hospital Detailed Information

30

10. Hosp002-3 - Hospital or Clinic Details 3rd Party: Specific Hospital Detailed Information

31

11. Test001-1 – Tests – 1st Party Contains New Submit Tab

12. Test001-3 – Tests – 3rd Party Contains new Submit Tab

32

13. Test002-1 - Test Details 1st Party: Specific Test Detailed Information

14. Test002-3 - Test Details 3rd Party: Specific Test Detailed Information

33

15. Medi001-1 – Medicines– 1st Party Contains New Language and Submit Tab

16. Medi001-3 – Medicines – 3rd Party Contains New Language and Submit Tab

34

17. Medi002-1 - Medicine Details 1st Party: Specific Medicine Detailed Information

35

18. Medi002-3 Medicine Details 3rd Party: Specific Medicine Detailed Information

36

19. Othr001-1 - Other Medical Information 1st Party: Other Medical Records

37

20. Othr001-3 - Other Medical Information 3rd Party: Other Medical Records

38

21. Othr002-1 - Details of Other Medical Information 1st Party: Details of Other Medical Information

39

22. Othr002-3 - Details of Other Medical Information 3rd Party: Details of Other Medical Information

40

D. Section: Activities/Training
1. Actv001-1 - Activities 1st Party: Activities

2. Actv001-3 - Activities 3rd Party: Activities

41

3. Wetr001-1 - Work and Education 1st Party: Work, Education & Training

4. Wetr001-3 Work and Education 3rd Party: Work, Education & Training

42

5. Voct001-1 - Vocational Rehabilitation 1st Party: Vocational Rehabilitation

6. Voct001-3 - Vocational Rehabilitation 3rd Party: Vocational Rehabilitation

43

E. Section: Review and Submit Pages
1. Rmks001-1 - Remarks 1st Party: Remarks

44

2. Rmks001-3 - Remarks 3rd Party: Remarks

45

3. Mdrf001-1 - Medical Release 1st Party: Medical Release Form

46

4. Mdrf001-3 - Medical Release 3rd Party: Medical Release Form

47

5. Revw001-1 – Summary - 1st Party Contains New Information Box and Submit Tab

48

6. Revw001-3 – Summary – 3rd Party Contains New Information Box and Submit Tab

49

7. Flup001 – Attach Files Contains New “Submit” Tab and Warning Notice

50

8. Conf001-1 - Confirmation 1st Party: Application Submission Confirmation

51

9. Conf001-3 - Confirmation 3rd Party: Application Submission Confirmation

52

10. Conf001-3-Rep Confirmation 3rd Party - Appointed Representative: Application Submission
Confirmation

53

11. Rcpt001 – Receipt

54

12. Covr001 - Cover Sheet Cover Sheet

55

Section: Lightboxes
1. NEW Screen – Checklist Help Pop-up

56

2. New Screen – Re-entry Number Help Pop-up

3. New Screen – Forgot or Lost Re-entry Number Help

57


File Typeapplication/pdf
AuthorBennett, Deborah Contractor
File Modified2019-02-01
File Created2019-02-01

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