Information Collection

Category III - Pain/Other Symptoms/Impairment Information - Seizure Questionnaire - Adult

IC 181780 under ICR 202604-0960-004 · OMB 0960-0555.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Category III - Seizure Questionnaire (CLMT) - Revised.pdf	Other-Seizure Questionnaire
Category III - Seizure Questionnaire (CLMT)-current.pdf Seizure Witness Questionnaire (3RD PTY) (current)	IC Document

IC Title:

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 404.1512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Seizure Questionnaire					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54,372

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	54,372	-2,045,628	2,100,000
Annual IC Time Burden (Hours)	22,655	-677,345	700,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Seizure Witness Questionnaire (3RD PTY) (current)		04/29/2026

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

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