Information Collection

Workers' Compensation/Public Disability Benefit Questionnaire

IC 9165 under ICR 200902-0960-005 · OMB 0960-0247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0247 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-546 Workers' Compensation/Public Disability Benefit Questionnaire Form
SSA-546 Workers' Compensation/Public Disability Benefit Questinn ssa-546.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Workers' Compensation/Public Disability Benefit Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.408

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-546	Workers' Compensation/Public Disability Benefit Questinnaire	ssa-546.pdf		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: 248,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	248,000	148,000	100,000
Annual IC Time Burden (Hours)	62,000	37,000	25,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.