Information Collection

Work History Report

IC 9542 under ICR 200702-0960-002 · OMB 0960-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3369-BK Work History Report	Form
SSA-3369-BK Work History Report ssa-3369bk revision.pdf	Form

IC Title:

Work History Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.912 20 CFR 404.1512 20 CFR 404.1560 20 CFR 404.1565 20 CFR 416.960 20 CFR 416.965

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3369-BK	Work History Report	ssa-3369bk revision.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,000	-850,000	871,000
Annual IC Time Burden (Hours)	21,000	-850,000	871,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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