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Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Evidence from Doctor or Hospital 20 CFR 404 Subpart I and 20 CFR 416 Subpart P

ICR 200603-0960-009 · OMB 0960-0722 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
9779 Request for Evidence from Doctor or Hospital 20 CFR 404 Subpart I and 20 CFR 416 Subpart P Form Migrated
ICR Details
0960-0722 200603-0960-009
Historical Active
SSA
Request for Evidence from Doctor or Hospital 20 CFR 404 Subpart I and 20 CFR 416 Subpart P
Existing collection in use without an OMB Control Number   No
Regular
Approved without change 05/19/2006
Retrieve Notice of Action (NOA) 03/21/2006
OMB approves this previously unapproved collection. SSA reported this violation in the most recent ICB. SSA agrees to identify and resolve any additional violations to ensure full compliance with the PRA. Additionally, upon resubmission of this collection for OMB approval, if this collection is not fully electronic, SSA will report to OMB on why full electronic submission has not been accomplished.
  Inventory as of this Action Requested Previously Approved
05/31/2009 05/31/2009
400,000 0 0
100,000 0 0
0 0 0
Claimants are required to provide medical evidence of their impairment(s) in pursuing a disability claim. SSA uses these forms to request medical evidence from sources (doctors and hospitals) where the claimant has been treated, seen or otherwise evaluated. Respondents are doctors and hospitals where the claimant has been evaluated.
None
None
No
1
IC Title Form No. Form Name
Request for Evidence from Doctor or Hospital 20 CFR 404 Subpart I and 20 CFR 416 Subpart P 1J, 2J
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 400,000 0 0 400,000 0 0
Annual Time Burden (Hours) 100,000 0 0 100,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/21/2006