Information Collection

Discrimination Complaint Form

IC 9560 under ICR 201603-0960-007 · OMB 0960-0585.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0585 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-437 Discrimination Complaint Form	Form and Instruction
SSA-437 Discrimination Complaint Form SSA-437-BK - Revised.pdf	Form and Instruction
SSA-437-BK - Current.pdf Current SSA-437	IC Document

IC Title:

Discrimination Complaint Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-437	Discrimination Complaint Form	SSA-437-BK - Revised.pdf		Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 255

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	255	115	140
Annual IC Time Burden (Hours)	255	115	140
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-437	SSA-437-BK - Current.pdf	06/20/2016

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