Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CE Claimant/Appointment Letter Information (subset of "CE Forms Samples" category) Unchanged 750000 62500 0 Other-Sample of Appointment Letter Included
CE Source Credentialing Information (Subset of "CE Sample Forms") Unchanged 3000 750 0 Form and Instruction N/A Sample CE Forms
Claimants re Report to Medical Provider (subset of "CE Forms Samples" category) Unchanged 1500000 125000 0 Other-Sample of state DDS Claimant Report Letter/Form
Connect Direct Transmission of MER Information (subset of "MER Samples" category) Unchanged 218400 54600 0 Other-Sample MER Information (same as previous IC, submitted through electronic Connect Direct system)
ERE transmission of MER forms (subset of "MER Samples" category) Unchanged 100800 11760 0 Other-ERE Transmission of "MER Samples" Category
MER Paper Submissions (subset of "MER Samples") category Unchanged 2480800 620200 0 Other-Sample of MER forms
Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category) Unchanged 285000 71250 0 Other-Sample of types of information sent through ERE; electronic version of CE paper
Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category) Unchanged 1215000 607500 0 Other-Samples of DDS CE Forms
Pain Questionnaire New 1000000 250000 0 Form Pain Questionnaire Pain Questionnaire
Total burden requested under this ICR: 7553000 1803560 0  
To view an IC, click on IC Title