COVID Screener Questionnaire

Social Security Administration (SSA) COVID-19 Symptoms Screener for Hearings

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0824 can be found here:

Documents and Forms

Document Name Document Type
OHO Screener Screenshots - Revised.pdf www.ssa.gov/appeals/hearing_inperson.html. Other-Internet Screens
COVID-19 Visitor Procedures Notice - Website Link - Revised.pdf Other-Notice
OHO Screener Screenshots - Current.pdf OHO Screener Screenshots - Current IC Document
COVID-19 Visitor Procedures Notice - Website Link - Current.pdf COVID-19 Visitor Procedures Notice - Website Link - Current IC Document

Information Collection (IC) Details

IC Title:	COVID Screener Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.929 20 CFR 416.1429 20 CFR 416.1433 20 CFR 418.1350 20 CFR 404.933 20 CFR 422.203

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Screens			OHO Screener Screenshots - Revised.pdf	www.ssa.gov/appeals/hearing_inperson.html.	Yes	Yes	Fillable Fileable Signable
Other-Notice			COVID-19 Visitor Procedures Notice - Website Link - Revised.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: 179,580	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	179,580	179,580
Annual IC Time Burden (Hours)	149,650	149,650
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OHO Screener Screenshots - Current	OHO Screener Screenshots - Current.pdf	03/31/2022
COVID-19 Visitor Procedures Notice - Website Link - Current	COVID-19 Visitor Procedures Notice - Website Link - Current.pdf	03/31/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.