Information Collection Request

Disability Case Development Information Collections

ICR 202402-0960-002 · OMB 0960-0555 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0960-0555 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information	Form	Unchanged	Available
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information	Form	Unchanged	Repair queued
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Unchanged	Available
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Unchanged	Repair queued
Justification for Non-Substantive Changes - 0960-0555.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-14	Available
Justification for Non-Substantive Changes - 0960-0555.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-14	Repair queued
Supporting Statement - 0555 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-04-04	Available
Supporting Statement - 0555 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-04-04	Repair queued

IC Document Collections

IC ID	Collection	Type	Status
9480	Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)	Other-Samples of DDS CE Forms	Unchanged
241087	Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)	Other- THCE Agreeement Call Script - Adult (revised).	Modified
181780	Category III - Pain/Other Symptoms/Impairment Information	Form	Unchanged
181780	Category III - Pain/Other Symptoms/Impairment Information	Form	Unchanged
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Unchanged
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Unchanged
179022	Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category)	Other-ERE Transmission of "MER Samples" Category	Unchanged
179020	Category II - MER Paper Submissions (subset of "MER Samples") category	Other-Sample of MER forms	Unchanged
179019	Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)	Other-Sample of state DDS Claimant Report Letter/Form	Unchanged
179018	Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)	Other-Sample of Appointment Letter Included	Unchanged
179017	Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category)	Other-Sample of types of information sent through ERE; electroni	Unchanged

ICR Details

Status	Active
Agency/Subagency	SSA
OMB Control No	0960-0555
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202008-0960-021
Date Submitted to OIRA	2024-02-14
Requested Expiration Date	1969-12-31