Work History Report

ICR 200106-0960-007

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
9541 Migrated
ICR Details
0960-0578 200106-0960-007
Historical Active 199806-0960-001
SSA
Work History Report
Revision of a currently approved collection   No
Regular
Approved without change 08/17/2001
Retrieve Notice of Action (NOA) 06/14/2001
  Inventory as of this Action Requested Previously Approved
08/31/2004 08/31/2004 08/31/2001
1,000,000 0 1,000,000
500,000 0 500,000
0 0 0

The information collected on form SSA-3369 is needed to determine disability by the State DDSs. The information will be used to document an individual's past work history. The respondents are applicants for disability benefits.

None
None


No

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

  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 1,000,000 1,000,000 0 0 0 0
Annual Time Burden (Hours) 500,000 500,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
06/14/2001


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