Information Collection

COVID Screener Questionnaire

IC 250661 under ICR 202112-0960-002 · OMB 0960-0824.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0824 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
OHO Screener Screenshots.docx	Other-Internet Screens
OHO Screener Screenshots.docx	Other-Internet Screens
COVID-19 Visitor Procedures Notice - website link.docx	Other-Notice
COVID-19 Visitor Procedures Notice - website link.docx	Other-Notice

IC Title:

COVID Screener Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.929 20 CFR 416.1429 20 CFR 416.1433 20 CFR 418.1350 20 CFR 404.933 20 CFR 422.203

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			OHO Screener Screenshots.docx	www.ssa.gov/appeals/hearing_inperson.html.	Yes	Yes	Fillable Fileable Signable
Other-Notice			COVID-19 Visitor Procedures Notice - website link.docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 179,580

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	179,580	179,580
Annual IC Time Burden (Hours)	149,650	149,650
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.