Information Collection

Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

IC 9455 under ICR 201302-0960-007 · OMB 0960-0542.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0542 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3376 Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)	Form
SSA-3376 Function Report-Child Age 1 to 3rd Birthday SSA-3376 Revised.pdf	Form
SSA-3375 Function Report-Child Birth to 1st Birthday SSA-3375 Revised.pdf	Form
SSA-3377 Function Report-Child Age 3 to 6th Birthday SSA-3377 Revised.pdf	Form
SSA-3378 Function Report - Child Age 6 to 12th Birthday SSA-3378 Revised.pdf	Form
SSA-3379 Function Report - Child Age 12 to 18th Birthday SSA-3379 Revised.pdf	Form
ssa-3375.pdf Current SSA-3375	IC Document
ssa-3376.pdf Current SSA-3376	IC Document
ssa-3377.pdf Current SSA-3377	IC Document
ssa-3378.pdf Current SSA-3378	IC Document
ssa-3379.pdf Current SSA-3379	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

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 416.912 20 CFR 416.924a (a) (2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3376	Function Report-Child Age 1 to 3rd Birthday	SSA-3376 Revised.pdf	Yes	No	Printable Only
Form	SSA-3375	Function Report-Child Birth to 1st Birthday	SSA-3375 Revised.pdf	Yes	No	Printable Only
Form	SSA-3377	Function Report-Child Age 3 to 6th Birthday	SSA-3377 Revised.pdf	No		Printable Only
Form	SSA-3378	Function Report - Child Age 6 to 12th Birthday	SSA-3378 Revised.pdf	Yes	No	Printable Only
Form	SSA-3379	Function Report - Child Age 12 to 18th Birthday	SSA-3379 Revised.pdf	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 660,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	660,000	160,000	500,000
Annual IC Time Burden (Hours)	220,000	53,333	166,667
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3375	ssa-3375.pdf	04/03/2013
Current SSA-3376	ssa-3376.pdf	04/03/2013
Current SSA-3377	ssa-3377.pdf	04/03/2013
Current SSA-3378	ssa-3378.pdf	04/03/2013
Current SSA-3379	ssa-3379.pdf	04/03/2013

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