Information Collection

Workers' Compensation/Public Disability Benefit Questionnaire

IC 9165 under ICR 201111-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-546 Workers' Compensation/Public Disability Benefit Questinnaire Workers' Compensation/Public Disability Benefit Questionnaire	Form
MCS screens.pdf	Other-MCS screens
SSA-546 Workers' Compensation/Public Disability Benefit Questinn SSA-546 (revised).pdf	Form
SSA-546.pdf SSA-546 (current)	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-546				Yes	Yes	Fillable Fileable
Other-MCS screens					Yes	Yes	Fillable Fileable Signable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	248,000	248,000
Annual IC Time Burden (Hours)	62,000	62,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-546 (current)		11/29/2011

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

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