Information Collection

Category III - Pain/Other Symptoms/Impairment Information

IC 181780 under ICR 202004-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information Form
Pain Questionnaire Pain Questionnaire Pain Impairment Questions - Revised.pdf Form
Pain Impairment Questions - Current.pdf Pain Impairment Questions - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Pain Questionnaire	Pain Questionnaire	Pain Impairment Questions - Revised.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: 2,100,000	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	2,100,000	2,100,000
Annual IC Time Burden (Hours)	700,000	700,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Pain Impairment Questions - Current	Pain Impairment Questions - Current.pdf	06/13/2017

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