REPORT OF FUNCTION, ADULT

ICR 199410-0960-001

OMB: 0960-0539

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
115726 Migrated
ICR Details
0960-0539 199410-0960-001
Historical Active
SSA
REPORT OF FUNCTION, ADULT
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/30/1994
Retrieve Notice of Action (NOA) 10/04/1994
  Inventory as of this Action Requested Previously Approved
01/31/1998 01/31/1998
2,164,000 0 0
541,000 0 0
0 0 0

THIS FORM WILL BE USED TO RECORD INFORMATION ABOUT HOW THE CLAIMANT'S CONDITION AFFECTS HIS OR HER ABILITY TO FUNCTION. THE RESPONDENTS WIL BE APPLICANTS FOR DISABILITY BENEFITS.

None
None


No

1
IC Title Form No. Form Name
REPORT OF FUNCTION, ADULT SSA-3373

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,164,000 0 0 2,164,000 0 0
Annual Time Burden (Hours) 541,000 0 0 541,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/04/1994


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