COVID Screener Questionnaire

Social Security Administration (SSA) COVID-19 Symptoms Screener for Hearings

Documents and Forms

Document Name Document Type
OHO Screener Screenshots.pdf www.ssa.gov/appeals/hearing_inperson.html. Other-Internet Screens
OHO Screener Screenshots.pdf www.ssa.gov/appeals/hearing_inperson.html. Other-Internet Screens
COVID-19 Visitor Procedures Notice - Website Link.pdf Other-Notice
COVID-19 Visitor Procedures Notice - Website Link.pdf Other-Notice

Information Collection (IC) Details

IC Title:	COVID Screener Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Screens			OHO Screener Screenshots.pdf	www.ssa.gov/appeals/hearing_inperson.html.	Yes	Yes	Fillable Fileable Signable
Other-Notice			COVID-19 Visitor Procedures Notice - Website Link.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 359,160	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	359,160	179,580	179,580
Annual IC Time Burden (Hours)	239,440	89,790	149,650
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.