Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category) Unchanged 1400000 700000 0 Other-Samples of DDS CE Forms
Other-Claimant Request with Cardiac Questionnaire
Other-Claimant Request with Fatigue Questionnaire
Other-Claimant Request with Headache Questionnaire
Other-Claimant Request with Pain Questionnaire
Other-Claimant Request with Seizure Questionnaire
Other-Claimant Request with Vision Questionnaire
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Unchanged 4000 1000 0 Form and Instruction N/A Sample CE Forms
Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category) Unchanged 296000 49333 0 Other-Sample of types of information sent through ERE; electronic version of CE paper
Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category) Unchanged 880000 73333 0 Other-Sample of Appointment Letter Included
Other-Rescheduled CE Appointment Notice to Claimant- Adult
Other-Rescheduled CE Appointment Notice to Claimant- Child
Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category) Unchanged 450000 37500 0 Other-Sample of state DDS Claimant Report Letter/Form
Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category) Modified 1175536 78369 0 Other- THCE Agreeement Call Script - Adult (revised).
Other- THCE Agreeement Call Script - Adult with Legal Guardian
Other- THCE Agreeement Call Script - Child (revised)
Other- THCE Agreement Form - Adult
Other- THCE Agreement Form - Adult
Other-THCE Agreement Form - Adult with Legal Guardian
Other- THCE Agreement Form - Child
Other- DCPS Scheduling Text and Email Consent Script
Other- DCPS Scheduling Text and Email Consent.
Category II - MER Paper Submissions (subset of "MER Samples") category Unchanged 3150000 1050000 0 Other-Sample of MER forms
Other-Doctor Evidence Request with Cardiac Questionnaire
Other-Doctor Evidence Request with Physical Report
Other-Doctor Evidence Request with Seizure Questionnaire
Other-Request for Speech and Language Questionnaire- Child 1-6
Other-Request for Speech and Language Questionnaire- Child 6-18
Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category) Unchanged 9450000 1890000 0 Other-ERE Transmission of "MER Samples" Category
Category III - Pain/Other Symptoms/Impairment Information Unchanged 2100000 700000 0 Form Pain Questionnaire Pain Questionnaire
Form N/A Muscle Examination
Other-CE- Arterial Doopler Evaluation With Toe
Other-CE-Fibromyalgia Evaluation Sheet
Other-CE_ Range of Motion Chart
Other-CE- Resting Doopler Evaluation
Other-Third Party Request with Seizure Witness Questionnaire
Total burden requested under this ICR: 18905536 4579535 0  
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