Information Collection

Employee Work Activity Questionnaire

IC 9380 under ICR 201101-0960-001 · OMB 0960-0483.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0483 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3033 Employee Work Activity Questionnaire	Form and Instruction
SSA-3033 Work Activity Questionnaire Revised SSA-3033.pdf	Form and Instruction
ssa-30331.pdf Current Version (unrevised) SSA-3033	IC Document

IC Title:

Employee Work Activity 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 404.1574(a)(1)-(3)

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-3033	Work Activity Questionnaire	Revised SSA-3033.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: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	3,750	3,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Version (unrevised) SSA-3033	ssa-30331.pdf	01/21/2011

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