Information Collection

Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

IC 9455 under ICR 201605-0960-002 · OMB 0960-0542.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0542 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3375 Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)	Form
New Privacy Act Statement for Forms SSA-3375 - SSA-3379 - 0542.pdf	Other-Revised Privacy Act Statement
SSA-3375 Function Report-Child Birth to 1st Birthday SSA-3375 - Revised Version.pdf	Form
SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday SSA-3376 - Revised Version.pdf	Form
SSA-3377-BK Function Report-Child Age 3 to 6th Birthday SSA-3377 - Revised Version.pdf	Form
SSA-3378-BK Function Report-Child Age 6 to 12th Birthday SSA-3378 - Revised Version.pdf	Form
SSA-3379-BK Function Report-Child Age 12 to 18th Birthday SSA-3379 - Revised Version.pdf	Form
SSA-3375 - Current Version.pdf Current SSA-3375	IC Document
SSA-3376 - Current Version.pdf Current SSA-3376	IC Document
SSA-3377 - Current Version.pdf Current SSA-3377	IC Document
SSA-3378 - Current Version.pdf Current SSA-3378	IC Document
SSA-3379 - Current Version.pdf Current SSA-3379	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

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 416.924a (a) (2) 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3375	Function Report-Child Birth to 1st Birthday	SSA-3375 - Revised Version.pdf	Yes	No	Fillable Printable
Form	SSA-3376-BK	Function Report-Child Age 1 to 3rd Birthday	SSA-3376 - Revised Version.pdf	No		Printable Only
Form	SSA-3377-BK	Function Report-Child Age 3 to 6th Birthday	SSA-3377 - Revised Version.pdf	No		Printable Only
Form	SSA-3378-BK	Function Report-Child Age 6 to 12th Birthday	SSA-3378 - Revised Version.pdf	No		Printable Only
Form	SSA-3379-BK	Function Report-Child Age 12 to 18th Birthday	SSA-3379 - Revised Version.pdf	No		Printable Only
Other-Revised Privacy Act Statement for Forms SSA-3375 - SSA-3379			New Privacy Act Statement for Forms SSA-3375 - SSA-3379 - 0542.pdf	No		Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 532,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	532,000	-128,000	660,000
Annual IC Time Burden (Hours)	177,333	-42,667	220,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3375	SSA-3375 - Current Version.pdf	09/02/2016
Current SSA-3376	SSA-3376 - Current Version.pdf	09/02/2016
Current SSA-3377	SSA-3377 - Current Version.pdf	09/02/2016
Current SSA-3378	SSA-3378 - Current Version.pdf	09/02/2016
Current SSA-3379	SSA-3379 - Current Version.pdf	09/02/2016

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