Information Collection

Disability Report - Adult, (Paper Version)

IC 9548 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⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-3368 Disability Report - Adult -- Revised Version Disability Report - Adult, (Paper Version)	Form and Instruction
SSA-3368 Disability Report - Adult -- Revised Version SSA-3368-BK -- Revised Version.pdf	Form and Instruction
SSA-3368-BK -- Current Version.pdf SSA-3368-BK -- Current Version	IC Document

IC Title:

Disability Report - Adult, (Paper 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
Form and Instruction	SSA-3368	Disability Report - Adult -- Revised Version	SSA-3368-BK -- Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,950

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	22,950	13,586	9,364
Annual IC Time Burden (Hours)	22,950	13,586	9,364
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3368-BK -- Current Version	SSA-3368-BK -- Current Version.pdf	06/12/2009

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