Information Collection

Development of Participation in a Vocational Rehabilitation or Similar Program

IC 9186 under ICR 201610-0960-003 · OMB 0960-0282.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0282 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-4290 Development of Participation in a Vocational Rehabilitation or Similar Program Form
Revised Privacy Act Statement.pdf Other-Revised PA Statement
SSA-4290 Development of Participation in a Vocational Rehabilitat SSA-4290-F5 - Revised (Fillable).pdf Form
SSA-4290-F5 - Current.pdf SSA-4290-F5 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Development of Participation in a Vocational Rehabilitation or Similar Program	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 404.1596 20 CFR 416.1338(c)-(d) 20 CFR 404.316(c) 20 CFR 404.337(c) 20 CFR 404.352(d) 20 CFR 404.1597(a) 20 CFR 404.1586(g) 20 CFR 416.1320(d) 20 CFR 416.1331(a)-(b) 20 CFR 416.1338 20 CFR 404.327 20 CFR 404.328

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4290	Development of Participation in a Vocational Rehabilitation or Similar Program	SSA-4290-F5 - Revised (Fillable).pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised Privacy Act Statement.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: 3,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4290-F5 Current Version	SSA-4290-F5 - Current.pdf	12/06/2016

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