Information Collection

Report To Social Security Administration About Workers' Compensation

IC 166813 under ICR 198408-0960-021 · OMB 0960-0367.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0367 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REPORT TO SOCIAL SECURITY ADMINISTRATION ABOUT WORKERS' COMPENSATION	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4679-SM				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1	-59,999	0	60,000
Annual IC Time Burden (Hours)	0	0	-2,000	2,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded

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