Information Collection

Pain Report - Child

IC 9452 under ICR 202609-0960-007 · OMB 0960-0540.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3371-BK Pain Report-Child Pain Report - Child	Form
Privacy Act Statement 0540 (revised).docx	Other-Privacy Act Statement (revised
SSA-3371-BK (Upload Documents screen shots).pdf	Other-Upload Document Screens
SSA-3371-BK Pain Report-Child SSA-3371-BK (revised).pdf	Form
SSA-3371-BK (current).pdf Current SSA-3371	IC Document

IC Title:

Pain Report - Child

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 404.512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3371-BK	No		Paper Only
Other-Privacy Act Statement (revised) 0540		No		Paper Only
Other-Upload Document Screens		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,602

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	1,602	102	1,500
Annual IC Time Burden (Hours)	2,163	438	1,725
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3371		09/17/2026

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

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