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

Documents and forms in this information collection
Document Name	Document Type
Category II - MER Paper Submission Samples - Revised.pdf	Other-Sample of MER forms
Category II - Cardiac Questionnaire (MER) - Revised.pdf	Other-Doctor Evidence Request with C
Doctor Evidence Request with Physical Report (1).pdf	Other-Doctor Evidence Request with P
Category II - Seizure Questionnaire (MER) - Revised.pdf	Other-Doctor Evidence Request with S
Category II - Speech and Language Questionnaire (MER) - Child 1-6 - Revised.pdf	Other-Request for Speech and Languag
Category II - Speech and Language Questionnaire (MER) - Child 6-18 - Revised.pdf	Other-Request for Speech and Languag
Category III - Seizure Witness Questionnaire (3RD PTY) - Revised.pdf	Other-Seizure Witness Questionnaire
Category II - Mental Status Questionnaire - Adult (MER) - New.pdf	Other-Mental Status Questionnaire -
Category II - Mental Status Questionnaire - Child (MER) - New.pdf	Other-Mental Status Questionnaire -
Category III - Request for Third Party Contact (CLMT) - New.pdf	Other-Request for Third Party Contac
Category II - Cardiac Questionnaire (MER) - Current.pdf Category II - Cardiac Questionnaire (MER) (current)	IC Document
Category II - Seizure Questionnaire (MER) - Current.pdf Category II - Seizure Questionnaire (MER) (current)	IC Document
Category III - Seizure Witness Questionnaire (3RD PTY) - Current.pdf Seizure Witness Questionnaire (3RD PTY) (current)	IC Document
Category II - Speech and Language Questionnaire (MER) - Child 1-6 - Current.pdf Request for Speech and Language Questionnaire- Child 1-6 (current)	IC Document
Category II - Speech and Language Questionnaire (MER) - Child 6-18 - Current.pdf Request for Speech and Language Questionnaire- Child 6-18 (current)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Category II - MER Paper Submissions (subset of "MER 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 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

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Electronic Capability
Other-Sample of MER forms	No	Paper Only
Other-Doctor Evidence Request with Cardiac Questionnaire	No	Paper Only
Other-Doctor Evidence Request with Physical Report	No	Paper Only
Other-Doctor Evidence Request with Seizure Questionnaire	No	Paper Only
Other-Request for Speech and Language Questionnaire- Child 1-6	No	Paper Only
Other-Request for Speech and Language Questionnaire- Child 6-18	No	Paper Only
Other-Seizure Witness Questionnaire (3RD PTY)	No	Paper Only
Other-Mental Status Questionnaire - Adult (MER) (new)	No	Paper Only
Other-Mental Status Questionnaire - Adult (MER) - New	No	Paper Only
Other-Request for Third Party Contact (CLMT) - New	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: 1,444,747

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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Category II - Cardiac Questionnaire (MER) (current)		04/13/2026
Category II - Seizure Questionnaire (MER) (current)		04/13/2026
Seizure Witness Questionnaire (3RD PTY) (current)		04/13/2026
Request for Speech and Language Questionnaire- Child 1-6 (current)		04/13/2026
Request for Speech and Language Questionnaire- Child 6-18 (current)		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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