Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment

Physical Residual Functional Capacity Assessment/Mental Residual Capacity Assessment

Documents and Forms

Document Name Document Type
Form SSA-4734-BK Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment Form
SSA-4734-BK Physical Residual Functional Capacity Assessment SSA-4737-BK.pdf Form
SSA-4734-F4-SUP Mental Residual Functional Capacity Assessment SSA-4734-F4-SUP.pdf Form

Information Collection (IC) Details

IC Title:	Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 416.945-.946 20 CFR 404.1545-.1546

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4734-BK	Physical Residual Functional Capacity Assessment	SSA-4737-BK.pdf		No		Paper Only
Form	SSA-4734-F4-SUP	Mental Residual Functional Capacity Assessment	SSA-4734-F4-SUP.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: 2,397,646	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,397,646	-24,219	2,421,865
Annual IC Time Burden (Hours)	799,215	-8,073	807,288
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.