OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Category II - MER Paper Submissions (subset of "MER Samples") category

IC 179020 under ICR 202604-0960-004 · OMB 0960-0555.

Documents and Forms
Document Name
Document Type
Other-Sample of MER forms
Other-Doctor Evidence Request with C
Other-Doctor Evidence Request with P
Other-Doctor Evidence Request with S
Other-Request for Speech and Languag
Other-Request for Speech and Languag
Other-Seizure Witness Questionnaire
Other-Mental Status Questionnaire -
Other-Mental Status Questionnaire -
Other-Request for Third Party Contac
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Category II - MER Paper Submissions (subset of "MER Samples") category
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.912 20 CFR 416.914 20 CFR 416.917 20 CFR 416.1014 20 CFR 416.903a 20 CFR 416.913 20 CFR 404.1503a 20 CFR 416.919 20 CFR 404.1513 20 CFR 404.1514 20 CFR 404.1512 20 CFR 404.1624 20 CFR 404.1517 20 CFR 416.1013 20 CFR 404.1519 20 CFR 404.1613 20 CFR 404.1614 20 CFR 416.1024

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Sample of MER forms Category II - MER Paper Submission Samples - Revised.pdf No   Paper Only
Other-Doctor Evidence Request with Cardiac Questionnaire Category II - Cardiac Questionnaire (MER) - Revised.pdf No   Paper Only
Other-Doctor Evidence Request with Physical Report Doctor Evidence Request with Physical Report (1).pdf No   Paper Only
Other-Doctor Evidence Request with Seizure Questionnaire Category II - Seizure Questionnaire (MER) - Revised.pdf No   Paper Only
Other-Request for Speech and Language Questionnaire- Child 1-6 Category II - Speech and Language Questionnaire (MER) - Child 1-6 - Revised.pdf No   Paper Only
Other-Request for Speech and Language Questionnaire- Child 6-18 Category II - Speech and Language Questionnaire (MER) - Child 6-18 - Revised.pdf No   Paper Only
Other-Seizure Witness Questionnaire (3RD PTY) Category III - Seizure Witness Questionnaire (3RD PTY) - Revised.pdf No   Paper Only
Other-Mental Status Questionnaire - Adult (MER) (new) Category II - Mental Status Questionnaire - Adult (MER) - New.pdf No   Paper Only
Other-Mental Status Questionnaire - Adult (MER) - New Category II - Mental Status Questionnaire - Child (MER) - New.pdf No   Paper Only
Other-Request for Third Party Contact (CLMT) - New Category III - Request for Third Party Contact (CLMT) - New.pdf No   Paper Only

Income Security General Retirement and Disability

 

1,444,747 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,444,747 0 0 -1,705,253 0 3,150,000
Annual IC Time Burden (Hours) 481,582 0 0 -568,418 0 1,050,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Category II - Cardiac Questionnaire (MER) (current) Category II - Cardiac Questionnaire (MER) - Current.pdf 04/13/2026
Category II - Seizure Questionnaire (MER) (current) Category II - Seizure Questionnaire (MER) - Current.pdf 04/13/2026
Seizure Witness Questionnaire (3RD PTY) (current) Category III - Seizure Witness Questionnaire (3RD PTY) - Current.pdf 04/13/2026
Request for Speech and Language Questionnaire- Child 1-6 (current) Category II - Speech and Language Questionnaire (MER) - Child 1-6 - Current.pdf 04/13/2026
Request for Speech and Language Questionnaire- Child 6-18 (current) Category II - Speech and Language Questionnaire (MER) - Child 6-18 - Current.pdf 04/13/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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