Category III - Pain/Other Symptoms/Impairment Information

Disability Case Development Information Collections

OMB: 0960-0555

IC ID: 181780

Documents and Forms

Document Name Document Type
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information Form
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information Form
CE - Arterial Doppler Evaluation With Toe.pdf Other-CE- Arterial Doopler Evaluatio
CE - Arterial Doppler Evaluation With Toe.pdf Other-CE- Arterial Doopler Evaluatio
CE - Fibromyalgia Evaluation Sheet.pdf Other-CE-Fibromyalgia Evaluation She
CE - Fibromyalgia Evaluation Sheet.pdf Other-CE-Fibromyalgia Evaluation She
CE - Range of Motion Chart.pdf Other-CE_ Range of Motion Chart
CE - Range of Motion Chart.pdf Other-CE_ Range of Motion Chart
CE - Resting Doppler Evaluation.pdf Other-CE- Resting Doopler Evaluation
CE - Resting Doppler Evaluation.pdf Other-CE- Resting Doopler Evaluation
Third Party Request with Seizure Witness Questionnaire.pdf Other-Third Party Request with Seizu
Third Party Request with Seizure Witness Questionnaire.pdf Other-Third Party Request with Seizu
Pain Questionnaire Pain Questionnaire Category III - Pain, Other Symptoms, Impairment Information - Revised.pdf Form
Pain Questionnaire Pain Questionnaire Category III - Pain, Other Symptoms, Impairment Information - Revised.pdf Form
Muscle Examination CE - Muscle Examination.pdf Form
Muscle Examination CE - Muscle Examination.pdf Form
Category III - Pain, Other Symptoms, Impairment Information - Current.pdf Category III - Pain, Other Symptoms, Impairment Information - Current IC Document
Category III - Pain, Other Symptoms, Impairment Information - Current.pdf Category III - Pain, Other Symptoms, Impairment Information - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Category III - Pain/Other Symptoms/Impairment Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Pain Questionnaire	Pain Questionnaire	Category III - Pain, Other Symptoms, Impairment Information - Revised.pdf	No		Paper Only
Form	N/A	Muscle Examination	CE - Muscle Examination.pdf	Yes	Yes	Fillable Fileable
Other-CE- Arterial Doopler Evaluation With Toe			CE - Arterial Doppler Evaluation With Toe.pdf	No		Paper Only
Other-CE-Fibromyalgia Evaluation Sheet			CE - Fibromyalgia Evaluation Sheet.pdf	No		Paper Only
Other-CE_ Range of Motion Chart			CE - Range of Motion Chart.pdf	No		Paper Only
Other-CE- Resting Doopler Evaluation			CE - Resting Doppler Evaluation.pdf	No		Paper Only
Other-Third Party Request with Seizure Witness Questionnaire			Third Party Request with Seizure Witness Questionnaire.pdf	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,100,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,100,000	2,100,000
Annual IC Time Burden (Hours)	700,000	700,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Category III - Pain, Other Symptoms, Impairment Information - Current	Category III - Pain, Other Symptoms, Impairment Information - Current.pdf	12/04/2020

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