Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)

Disability Case Development Information Collections

Documents and Forms

Document Name Document Type
Category I - CE a) Credentialing - Revised.pdf Other-Samples of DDS CE Forms
Category I - CE a) Credentialing - Revised.pdf Other-Samples of DDS CE Forms
Claimant Request with Cardiac Questionnaire.pdf Other-Claimant Request with Cardiac
Claimant Request with Cardiac Questionnaire.pdf Other-Claimant Request with Cardiac
Claimant Request with Fatigue Questionnaire.pdf Other-Claimant Request with Fatigue
Claimant Request with Fatigue Questionnaire.pdf Other-Claimant Request with Fatigue
Claimant Request with Headache Questionnaire.pdf Other-Claimant Request with Headache
Claimant Request with Headache Questionnaire.pdf Other-Claimant Request with Headache
Claimant Request with Pain Questionnaire.pdf Other-Claimant Request with Pain Que
Claimant Request with Pain Questionnaire.pdf Other-Claimant Request with Pain Que
Claimant Request with Seizure Questionnaire.pdf Other-Claimant Request with Seizure
Claimant Request with Seizure Questionnaire.pdf Other-Claimant Request with Seizure
Claimant Request with Vision Questionnaire.pdf Other-Claimant Request with Vision Q
Claimant Request with Vision Questionnaire.pdf Other-Claimant Request with Vision Q
Category I - CE a) Paper Submissions Samples - Current.pdf Category I - CE a) Paper Submissions Samples - Current IC Document
Category I - CE a) Paper Submissions Samples - Current.pdf Category I - CE a) Paper Submissions Samples - Current IC Document

Information Collection (IC) Details

IC Title:	Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.919 20 CFR 404.1513 20 CFR 416.918(c) 20 CFR 416.917 20 CFR 404.1514 20 CFR 404.1512 20 CFR 416.1013 20 CFR 416.914 20 CFR 404.1518(c) 20 CFR 404.1503a 20 CFR 404.1517 20 CFR 404.1613 20 CFR 404.1519 20 CFR 404.1614 20 CFR 404.1624 20 CFR 404.1024 20 CFR 416.1014 20 CFR 416.903a 20 CFR 416.912 20 CFR 416.913

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Samples of DDS CE Forms	Category I - CE a) Credentialing - Revised.pdf	No	Paper Only
Other-Claimant Request with Cardiac Questionnaire	Claimant Request with Cardiac Questionnaire.pdf	No	Paper Only
Other-Claimant Request with Fatigue Questionnaire	Claimant Request with Fatigue Questionnaire.pdf	No	Paper Only
Other-Claimant Request with Headache Questionnaire	Claimant Request with Headache Questionnaire.pdf	No	Paper Only
Other-Claimant Request with Pain Questionnaire	Claimant Request with Pain Questionnaire.pdf	No	Paper Only
Other-Claimant Request with Seizure Questionnaire	Claimant Request with Seizure Questionnaire.pdf	No	Paper Only
Other-Claimant Request with Vision Questionnaire	Claimant Request with Vision Questionnaire.pdf	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,400,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,400,000	1,400,000
Annual IC Time Burden (Hours)	700,000	700,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Category I - CE a) Paper Submissions Samples - Current	Category I - CE a) Paper Submissions Samples - Current.pdf	12/04/2020

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