Information Collection

Disability Report - Adult, (Internet Version)

IC 179420 under ICR 200904-0960-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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
i3368 Screenshots -- Revised.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Other-SSA-3368 (Internet)
i3368 Privacy Act Statement.doc	Other-Privacy Act Statement
Internet Screens -- Current.pdf i3368 -- Current Screens	IC Document

IC Title:

Disability Report - Adult, (Internet Version)

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 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)				https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable
Other-Privacy Act Statement					Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 319,994

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	319,994	101,089	117,770	101,135
Annual IC Time Burden (Hours)	479,991	151,633	75,521	252,837
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
i3368 -- Current Screens		06/12/2009

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

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