Information Collection

Claimant's Medication - PDF/Paper Version

IC 43700 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⚠️ Notice: This information collection may be referencing outdated material.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
Form HA-4632 Claimant's Medication - PDF/Paper Version	Form
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 Medication - PDF/Paper 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 404.1512 20 CFR 416.912

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
Form	HA-4632	Claimant's Medications	HA-4632 - Revised Version.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: 53,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	53,200	33,200	20,000
Annual IC Time Burden (Hours)	39,900	34,900	5,000
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.