Information Collection

Report of Adult Functioning-Employer

IC 221156 under ICR 201604-0960-014 · OMB 0960-0805.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0805 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3385-BK Report of Adult Functioning-Employer	Form
SSA-3385-BK Report of Adult Functioning-Employer SS3385BK.PDF	Form

IC Title:

Report of Adult Functioning-Employer

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

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	SSA-3385-BK	Report of Adult Functioning-Employer	SS3385BK.PDF		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Farms, Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,900	3,900
Annual IC Time Burden (Hours)	1,300	1,300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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