View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Category II - MER Paper Submissions (subset of "MER Samples") category
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.912 20 CFR 416.914 20 CFR 416.917 20 CFR 416.1014 20 CFR 416.903a 20 CFR 416.913 20 CFR 404.1503a 20 CFR 416.919 20 CFR 404.1513 20 CFR 404.1514 20 CFR 404.1512 20 CFR 404.1624 20 CFR 404.1517 20 CFR 416.1013 20 CFR 404.1519 20 CFR 404.1613 20 CFR 404.1614 20 CFR 416.1024

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Sample of MER forms No   Paper Only
Other-Doctor Evidence Request with Cardiac Questionnaire No   Paper Only
Other-Doctor Evidence Request with Physical Report No   Paper Only
Other-Doctor Evidence Request with Seizure Questionnaire No   Paper Only
Other-Request for Speech and Language Questionnaire- Child 1-6 No   Paper Only
Other-Request for Speech and Language Questionnaire- Child 6-18 No   Paper Only
Other-Seizure Witness Questionnaire (3RD PTY) No   Paper Only
Other-Mental Status Questionnaire - Adult (MER) (new) No   Paper Only
Other-Mental Status Questionnaire - Adult (MER) - New No   Paper Only
Other-Request for Third Party Contact (CLMT) - New No   Paper Only

Income Security General Retirement and Disability

 

1,444,747 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested 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 1,444,747 0 0 -1,705,253 0 3,150,000
Annual IC Time Burden (Hours) 481,582 0 0 -568,418 0 1,050,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Category II - Cardiac Questionnaire (MER) (current) 04/13/2026
Category II - Seizure Questionnaire (MER) (current) 04/13/2026
Seizure Witness Questionnaire (3RD PTY) (current) 04/13/2026
Request for Speech and Language Questionnaire- Child 1-6 (current) 04/13/2026
Request for Speech and Language Questionnaire- Child 6-18 (current) 04/13/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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