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20 CFR 404.1503b(c) & 416.903b(c)
Evidence From Excluded Medical Sources of Evidence
OMB: 0960-0803
IC ID: 222015
OMB.report
SSA
OMB 0960-0803
ICR 201805-0960-002
IC 222015
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0803 can be found here:
2023-06-06 - Revision of a currently approved collection
2019-08-16 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
BBA 812 - Paper Fact Sheet.pdf
Instruction
BBA812 - Internet Fact Sheet Screen Shots.pdf
www.ssa.gov
Instruction
BBA 812 - Model Repsonse - For Sections 208 or 1632 of the Act.pdf
www;ssa.gov
Other-Sample Template
BBA 812 - Model Response - For Section 1128 of the Act.pdf
www.ssa.gov
Other-Sample Template
BBA 812 - Model Response - For Section 1129 of the Act.pdf
www.ssa.gov
Other-Sample Template
Sample BBA 812 Notification Letter.pdf
Other-Sample Notice for Section 812
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
20 CFR 404.1503b(c) & 416.903b(c)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
20 CFR 404.1503b(c)
20 CFR 416.903b(c)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
BBA 812 - Paper Fact Sheet.pdf
No
Paper Only
Instruction
BBA812 - Internet Fact Sheet Screen Shots.pdf
www.ssa.gov
Yes
No
Printable Only
Other-Sample Template
BBA 812 - Model Repsonse - For Sections 208 or 1632 of the Act.pdf
www;ssa.gov
Yes
No
Printable Only
Other-Sample Template
BBA 812 - Model Response - For Section 1128 of the Act.pdf
www.ssa.gov
Yes
No
Printable Only
Other-Sample Template
BBA 812 - Model Response - For Section 1129 of the Act.pdf
www.ssa.gov
Yes
No
Printable Only
Other-Sample Notice for Section 812
Sample BBA 812 Notification Letter.pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
50
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
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
3,000
0
0
0
0
3,000
Annual IC Time Burden (Hours)
1,000
0
0
0
0
1,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.