Information Collection

Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)

IC 9480 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⚠️ Notice: This information collection may be referencing outdated material.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
Category I - CE a) Credentialing - Revised.pdf	Other-Samples of DDS CE Forms
Category I - CE a) Credentialing - Revised.pdf	Other-Samples of DDS CE Forms
Claimant Request with Cardiac Questionnaire.pdf	Other-Claimant Request with Cardiac
Claimant Request with Cardiac Questionnaire.pdf	Other-Claimant Request with Cardiac
Claimant Request with Fatigue Questionnaire.pdf	Other-Claimant Request with Fatigue
Claimant Request with Fatigue Questionnaire.pdf	Other-Claimant Request with Fatigue
Claimant Request with Headache Questionnaire.pdf	Other-Claimant Request with Headache
Claimant Request with Headache Questionnaire.pdf	Other-Claimant Request with Headache
Claimant Request with Pain Questionnaire.pdf	Other-Claimant Request with Pain Que
Claimant Request with Pain Questionnaire.pdf	Other-Claimant Request with Pain Que
Claimant Request with Seizure Questionnaire.pdf	Other-Claimant Request with Seizure
Claimant Request with Seizure Questionnaire.pdf	Other-Claimant Request with Seizure
Claimant Request with Vision Questionnaire.pdf	Other-Claimant Request with Vision Q
Claimant Request with Vision Questionnaire.pdf	Other-Claimant Request with Vision Q
Category I - CE a) Paper Submissions Samples - Current.pdf Category I - CE a) Paper Submissions Samples - Current	IC Document
Category I - CE a) Paper Submissions Samples - Current.pdf Category I - CE a) Paper Submissions Samples - Current	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.919 20 CFR 404.1513 20 CFR 416.918(c) 20 CFR 416.917 20 CFR 404.1514 20 CFR 404.1512 20 CFR 416.1013 20 CFR 416.914 20 CFR 404.1518(c) 20 CFR 404.1503a 20 CFR 404.1517 20 CFR 404.1613 20 CFR 404.1519 20 CFR 404.1614 20 CFR 404.1624 20 CFR 404.1024 20 CFR 416.1014 20 CFR 416.903a 20 CFR 416.912 20 CFR 416.913

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Electronic Capability
Other-Samples of DDS CE Forms	No	Paper Only
Other-Claimant Request with Fatigue Questionnaire	No	Paper Only
Other-Claimant Request with Headache Questionnaire	No	Paper Only
Other-Claimant Request with Pain Questionnaire	No	Paper Only
Other-Claimant Request with Seizure Questionnaire	No	Paper Only
Other-Claimant Request with Vision Questionnaire	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: 1,400,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,400,000	1,400,000
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 I - CE a) Paper Submissions Samples - 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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