Information Collection

Claimant's Medications - ERE Internet Version

IC 189495 under ICR 202111-0960-001 · OMB 0960-0289.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0289 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Electronic Record Express - Representative Upload Files Instructions (Internet Screens).pdf	Other-Internet Screens
Electronic Record Express - Representative Upload Files Instructions (Internet Screens).pdf	Other-Internet Screens
HA-4632 Claimant's Medications HA-4632 - Revised Version.pdf	Form
HA-4632 Claimant's Medications HA-4632 - Revised Version.pdf	Form
HA-4632 - Current Version.pdf Current HA-4632	IC Document
HA-4632 - Current Version.pdf Current HA-4632	IC Document

IC Title:

Claimant's Medications - ERE Internet Version

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 406.912 20 CFR 404.1512

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
Other-Internet Screens			Electronic Record Express - Representative Upload Files Instructions (Internet Screens).pdf		Yes	Yes	Fillable Fileable Signable
Form	HA-4632	Claimant's Medications	HA-4632 - Revised Version.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 136,800

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	136,800	-43,200	180,000
Annual IC Time Burden (Hours)	34,200	-10,800	45,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-4632	HA-4632 - Current Version.pdf	11/02/2021

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