Disability Report - Adult, (Internet Version)

Disability Report - Adult

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0579 can be found here:

Documents and Forms

Document Name Document Type
i3368 Screen shots Revised.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp Other-SSA-3368 (Internet)
Internet Screens -- Current.pdf i3368 -- Current Screens IC Document
i3368 Privacy Act Statement Current.doc PAS Current Version IC Document

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSA-3368 (Internet)			i3368 Screen shots Revised.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,060,360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,060,360	639,134	421,226
Annual IC Time Burden (Hours)	1,590,540	958,701	631,839
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
i3368 -- Current Screens	Internet Screens -- Current.pdf	06/12/2009
PAS Current Version	i3368 Privacy Act Statement Current.doc	05/07/2015

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