OMB.report

Federal forms, ICRs, and supporting documents

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

View Information Collection (IC)

Category III - Pain/Other Symptoms/Impairment Information - Seizure Witness Questionnaire – Adult
 
No New
 
Voluntary
 
20 CFR 416.912 20 CFR 404.1512

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Seizure Witness Questionnaire (3RD PTY) Category III - Seizure Witness Questionnaire (3RD PTY) - Revised.pdf No   Paper Only

Income Security General Retirement and Disability

 

8,765 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 8,765 0 0 8,765 0 0
Annual IC Time Burden (Hours) 3,652 0 0 3,652 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Seizure Witness Questionnaire (3RD PTY) (current) Category III - Seizure Witness Questionnaire (3RD PTY) - Current.pdf 04/29/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].