Information Collection

Disability Report - Adult, 20 CFR 404.1512 and 416.912(Internet)

IC 179420 under ICR 200901-0960-007 · OMB 0960-0579.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0579 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Internet.pdf eis.ba.ssa.gov/appages/i3369Public_November06/ee004.html	Other-SSA-3368 (Internet)
PRA Statement 150.doc PRA Statement	IC Document

IC Title:

Disability Report - Adult, 20 CFR 404.1512 and 416.912(Internet)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

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
Other-SSA-3368 (Internet)			Internet.pdf	http://eis.ba.ssa.gov/appages/i3369Public_November06/ee004.html	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 101,135

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 3 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	101,135	101,135
Annual IC Time Burden (Hours)	252,837	252,837
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRA Statement	PRA Statement 150.doc	05/03/2007

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