Information Collection

Medicare-only MCS SSA-1 screens

IC 191244 under ICR 202101-0960-004 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA-1 MCS Screens (IC 2).pdf in field office	Other-MCS screens for Medicare-only
SSA-1 MCS Screens (IC 2).pdf in field office	Other-MCS screens for Medicare-only
PCS Screen Package.pdf	Other-Intranet Screens
PCS Screen Package.pdf	Other-Intranet Screens
PCS Privacy Act Statement.pdf	Other-Privacy Act Statement for PCS
PCS Privacy Act Statement.pdf	Other-Privacy Act Statement for PCS

IC Title:

Medicare-only MCS SSA-1 screens

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 404.1501-.1512 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.310-.311 20 CFR 404.601-.603

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-MCS screens for Medicare-only (will be modified in interview as necessary)	SSA-1 MCS Screens (IC 2).pdf	in field office	Yes	Yes	Fillable Fileable Signable
Other-Intranet Screens	PCS Screen Package.pdf		Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement for PCS	PCS Privacy Act Statement.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 204,380

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	204,380	204,380
Annual IC Time Burden (Hours)	23,844	23,844
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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