Information Collection

Disability Report-Appeal - SSA-3441-BK (Paper Version)

IC 43698 under ICR 201111-0960-005 · OMB 0960-0144.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0144 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3441-BK Disability Report-Appeal - SSA-3441-BK (Paper Version)	Form and Instruction
SSA-3441-BK Disability Report--Appeal SSA-3441 (Revised Version).pdf	Form and Instruction
SSA-3441 (Current Version).pdf Current SSA-3441-BK	IC Document

IC Title:

Disability Report-Appeal - SSA-3441-BK (Paper Version)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.916(c) 20 CFR 405 20 CFR 404.1512 20 CFR 416.912 20 CFR 416.1416(c) 20 CFR 422.140

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-3441-BK	Disability Report--Appeal	SSA-3441 (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: 5,604

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,604	-7,000	12,604
Annual IC Time Burden (Hours)	4,203	-5,250	9,453
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3441-BK	SSA-3441 (Current Version).pdf	12/06/2011

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