Information Collection

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

IC 280141 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 Witness Questionnaire (3RD PTY) - Revised.pdf	Other-Seizure Witness Questionnaire
Category III - Seizure Witness Questionnaire (3RD PTY) - Current.pdf Seizure Witness Questionnaire (3RD PTY) (current)	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

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 Witness Questionnaire (3RD PTY)					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,765

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
Annual Number of Responses for this IC	8,765	8,765
Annual IC Time Burden (Hours)	3,652	3,652
Annual IC Cost Burden (Dollars)	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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