Information Collection

Disability Report - Adult, (Internet Version)

IC 179420 under ICR 201205-0960-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
i3368 Screenshots -- Revised.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Other-SSA-3368 (Internet)
i3368 Privacy Act Statement.doc	Other-Privacy Act Statement
i3368 Screenshots - Revised to Include CAL.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Other-Internet Screens
Internet Screens -- Current.pdf i3368 -- Current Screens	IC Document

IC Title:

Disability Report - Adult, (Internet 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 404.1512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSA-3368 (Internet)	i3368 Screenshots -- Revised.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable
Other-Privacy Act Statement	i3368 Privacy Act Statement.doc		Yes	Yes	Printable Only
Other-Internet Screens	i3368 Screenshots - Revised to Include CAL.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	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: 421,226

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	421,226	10,264	90,968	319,994
Annual IC Time Burden (Hours)	631,839	15,396	136,452	479,991
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
i3368 -- Current Screens	Internet Screens -- Current.pdf	06/12/2009

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