Addendum to the Supporting Statement 0960-0578

Addendum to the Supporting Statement for

Work History Report

Form SSA-3369-BK

CFR 404.1512, 416.912, 404.1560, 404.1565, 416.960 and 416.965

OMB 0960-0578

Creating a Different Modality of IC

We are replacing the standard PDF file with the fillable PDF file, which is available internally and to the public on the agency internet site. This version, which respondents can complete and mail, fax, or deliver by hand, will save time for both respondents and SSA/DDS employees because the typed form will be legible and easy to read.

Some individuals find the fillable PDF format easier to use. We want to ensure that the agency provides effective communication and is compliance with the requirements of 45 C.F.R. § 85.51 and section 504 of the Rehabilitation Act of 1973. We propose the fillable PDF file as a more accessible modality.

Other Minor Revisions to the Collection Instrument

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.