Information Collection

Child-Care Dropout Questionnaire

IC 9367 under ICR 201303-0960-007 · OMB 0960-0474.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0474 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-4162 Child-Care Dropout Questionnaire Form
MCS 005.doc Other-MCS Screens
SSA-4162 Child-Care Dropout Questionnaire SSA-4162 (Revised).pdf Form
SSA-4162 (current).pdf SSA-4162 (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Child-Care Dropout 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 404.211(e)(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4162	Child-Care Dropout Questionnaire	SSA-4162 (Revised).pdf		No		Paper Only
Other-MCS Screens			MCS 005.doc		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: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4162 (current)	SSA-4162 (current).pdf	04/04/2013

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