Information Collection

Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)

IC 241087 under ICR 202402-0960-002 · OMB 0960-0555.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
THCE Agreeement Call Script - Adult (revised).pdf	Other- THCE Agreeement Call Script -
THCE Agreeement Call Script - Adult (revised).pdf	Other- THCE Agreeement Call Script -
THCE Agreeement Call Script - Adult with Legal Guardian (revised).pdf	Other- THCE Agreeement Call Script -
THCE Agreeement Call Script - Adult with Legal Guardian (revised).pdf	Other- THCE Agreeement Call Script -
THCE Agreeement Call Script - Child (revised).pdf	Other- THCE Agreeement Call Script -
THCE Agreeement Call Script - Child (revised).pdf	Other- THCE Agreeement Call Script -
THCE Agreement Form - Adult (revised).pdf	Other- THCE Agreement Form - Adult
THCE Agreement Form - Adult (revised).pdf	Other- THCE Agreement Form - Adult
THCE Agreement Form - Adult (revised).pdf	Other- THCE Agreement Form - Adult
THCE Agreement Form - Adult (revised).pdf	Other- THCE Agreement Form - Adult
THCE Agreement Form - Adult with Legal Guardian (revised).pdf	Other-THCE Agreement Form - Adult wi
THCE Agreement Form - Adult with Legal Guardian (revised).pdf	Other-THCE Agreement Form - Adult wi
THCE Agreement Form - Child (revised).pdf	Other- THCE Agreement Form - Child
THCE Agreement Form - Child (revised).pdf	Other- THCE Agreement Form - Child
Telehealth Consultative Examination Agreement Form (current).pdf Telehealth Consultative Examination Agreement Form	IC Document
Telehealth Consultative Examination Agreement Form (current).pdf Telehealth Consultative Examination Agreement Form	IC Document
Telehealth Consultative Examinaton Agreement Call Script (current).pdf Telehealth Consultative Examination Agreement Call Script (current)	IC Document
Telehealth Consultative Examinaton Agreement Call Script (current).pdf Telehealth Consultative Examination Agreement Call Script (current)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)

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 404.1514 20 CFR 404.1517 20 CFR 404.1518(c) 20 CFR 404.1519 20 CFR 404.1613 20 CFR 404.1614 20 CFR 404.1624 20 CFR 416.903a 20 CFR 416.912 20 CFR 416.913 20 CFR 416.914 20 CFR 416.917 20 CFR 416.918(c) 20 CFR 416.919 20 CFR 416.1013 20 CFR 416.1014 20 CFR 416.1024 20 CFR 404.1503a 20 CFR 404.1512 20 CFR 404.1513

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other- THCE Agreeement Call Script - Adult (revised).	THCE Agreeement Call Script - Adult (revised).pdf	No		Paper Only
Other- THCE Agreeement Call Script - Adult with Legal Guardian	THCE Agreeement Call Script - Adult with Legal Guardian (revised).pdf	No		Paper Only
Other- THCE Agreeement Call Script - Child (revised)	THCE Agreeement Call Script - Child (revised).pdf	No		Paper Only
Other- THCE Agreement Form - Adult	THCE Agreement Form - Adult (revised).pdf	Yes	Yes	Fillable Fileable
Other- THCE Agreement Form - Adult	THCE Agreement Form - Adult (revised).pdf	Yes	Yes	Fillable Fileable
Other-THCE Agreement Form - Adult with Legal Guardian	THCE Agreement Form - Adult with Legal Guardian (revised).pdf	Yes	Yes	Fillable Fileable
Other- THCE Agreement Form - Child	THCE Agreement Form - Child (revised).pdf	Yes	Yes	Fillable Fileable

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: 128,248

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	128,248	118,248	10,000
Annual IC Time Burden (Hours)	10,687	9,854	833
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Telehealth Consultative Examination Agreement Form	Telehealth Consultative Examination Agreement Form (current).pdf	02/14/2024
Telehealth Consultative Examination Agreement Call Script (current)	Telehealth Consultative Examinaton Agreement Call Script (current).pdf	02/14/2024

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