Information Collection

Discrimination Complaint Form

IC 9560 under ICR 201001-0960-008 · OMB 0960-0585.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0585 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-437 Discrimination Complaint Form Discrimination Complaint Form	Form and Instruction
SSA-437 Discrimination Complaint Form SSA-437 - Revised Version.pdf	Form and Instruction
SSA-437 - Current Version.pdf Current SSA-437	IC Document

IC Title:

Discrimination Complaint Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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-437				No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 140

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	Previously Approved
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-437		03/26/2010

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

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