Pain Report - Child

Documents and Forms

Document Name Document Type
Form SSA-3371-BK Pain Report - Child Form
Prvacy Act Statement 0540 (revised).docx Other-Privacy Act Statement (revised
PRA Statement 0540 (revised).docx Other-Paperwork Reduction Act (revis
SSA-3371-BK Pain Report-Child SSA-3371-BK (revised).pdf Form
SSA-3371-BK (current).pdf Current SSA-3371 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pain Report - Child	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 404.512 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-3371-BK	Pain Report-Child	SSA-3371-BK (revised).pdf	No	Paper Only
Other-Privacy Act Statement (revised) 0540			Prvacy Act Statement 0540 (revised).docx	No	Paper Only
Other-Paperwork Reduction Act (revised)			PRA Statement 0540 (revised).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: 1,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,500	-248,500	250,000
Annual IC Time Burden (Hours)	1,725	-60,775	62,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3371	SSA-3371-BK (current).pdf	02/01/2022

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