Information Collection

Category III - Pain/Other Symptoms/Impairment Information

IC 181780 under ICR 202412-0960-005 · OMB 0960-0555.

⚠️ Notice: This information collection may be referencing outdated material.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

2026-04-29 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information	Form
Form Pain Questionnaire Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information	Form
Muscle Examination 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Pain Questionnaire	No		Paper Only
Form	N/A	Yes	Yes	Fillable Fileable
Other-CE- Arterial Doopler Evaluation With Toe		No		Paper Only
Other-CE-Fibromyalgia Evaluation Sheet		No		Paper Only
Other-CE_ Range of Motion Chart		No		Paper Only
Other-CE- Resting Doopler Evaluation		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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Category III - Pain, Other Symptoms, Impairment Information - Current		12/04/2020

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

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