Work History Report

ICR 199707-0960-008

OMB: 0960-0578

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
9539 Migrated
ICR Details
0960-0578 199707-0960-008
Historical Active
SSA
Work History Report
New collection (Request for a new OMB Control Number)   No
Emergency 07/31/1997
Approved without change 07/30/1997
Retrieve Notice of Action (NOA) 07/23/1997
This information collection is approved through 1-98 under the following condition: SSA will provide an analysis of the results of this prototype upon submission of the permanent form.
  Inventory as of this Action Requested Previously Approved
01/31/1998 01/31/1998
5,000 0 0
2,500 0 0
0 0 0

The information collected will be used by the Disability Determination Services in the determination of disability. The form records information about the claimant's work history in the past 15 years. This information is compared to the claimant's residual functional capacity to determine if the claimant is able to perform his or her usual job or other jobs.

None
None


No

1
IC Title Form No. Form Name
Work History Report SSA-3369-TEST

  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 5,000 0 0 5,000 0 0
Annual Time Burden (Hours) 2,500 0 0 2,500 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.
07/23/1997


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