OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Pain Report - Child

OMB 0960-0540 ยท SSA.

OMB 0960-0540

SSA requests information on Form SSA-3371-BK to provide disability interviewers, as well as applicants or claimants in self-help situations, with a convenient means to record information about the claimant's pain or other symptoms. The State disability determination services (DDS) adjudicators and administrative law judges then use the information to assess the effects of symptoms on function for purposes of determining disability under the Social Security Act. The respondents are applicants for or claimants of Supplemental Security Income (SSI) benefits.

The latest form for Pain Report - Child expires 2026-10-31 and is listed under ICR 202112-0960-006.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-3371-BK Pain Report - ChildForm
Addendum - 0540.docx Supplementary Document
Supporting Statement - 0540 (Final).docxSupporting Statement A
Pain Report - Child Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202112-0960-006 Revision of a currently approved collection 2022-02-25 Approved without change
201810-0960-012 Revision of a currently approved collection 2019-01-25 Approved without change
201509-0960-004 Revision of a currently approved collection 2015-11-27 Approved without change
201210-0960-003 Revision of a currently approved collection 2013-01-15 Approved without change
200911-0960-001 Revision of a currently approved collection 2010-02-05 Approved without change
200612-0960-007 Extension without change of a currently approved collection 2007-02-26 Approved without change
200403-0960-008 Extension without change of a currently approved collection 2004-03-12 Approved without change
200104-0960-006 Extension without change of a currently approved collection 2001-04-23 Approved without change
199802-0960-009 Extension without change of a currently approved collection 1998-02-24 Approved without change
199410-0960-002 New collection (Request for a new OMB Control Number) 1994-10-05 Approved without change