20 CFR 404.1503b(c) & 416.903b(c)

Statement From Excluded Medical Sources of Evidence

Documents and Forms

Document Name Document Type
BBA 812 - Paper Fact Sheet - Revised.pdf Instruction
BBA 812 - Paper Fact Sheet - Revised.pdf Instruction
BBA 812 - Internet Fact Sheet Screen Shots - Revised.pdf www.ssa.gov Instruction
BBA 812 - Internet Fact Sheet Screen Shots - Revised.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 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 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
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
Sample BBA 812 Notification Letter.pdf Other-Sample Notice for Section 812

Information Collection (IC) Details

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 416.903b(c) 20 CFR 404.1503b(c)

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	BBA 812 - Paper Fact Sheet - Revised.pdf		No		Paper Only
Instruction	BBA 812 - Internet Fact Sheet Screen Shots - Revised.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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	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: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	-2,400	3,000
Annual IC Time Burden (Hours)	200	-800	1,000
Annual IC Cost Burden (Dollars)	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.