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Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Other-Seizure Questionnaire
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Category III - Pain/Other Symptoms/Impairment Information - Seizure Questionnaire - Adult
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.1512 20 CFR 416.912

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Seizure Questionnaire Category III - Seizure Questionnaire (CLMT) - Revised.pdf No   Paper Only

Income Security General Retirement and Disability

 

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

Title Document Date Uploaded
Seizure Witness Questionnaire (3RD PTY) (current) Category III - Seizure Questionnaire (CLMT)-current.pdf 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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