Information Collection

Work History Report

IC 9542 under ICR 201701-0960-017 · OMB 0960-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3369 Work History Report	Form and Instruction
Privacy Act Statement Revised.doc	Other-Revised Privacy Act Statement
Revised PRA.doc	Other-Revised PRA
SSA-3369 Work History Report SSA-3369-BK- (revised).pdf	Form and Instruction
SSA-3369-BK (current).pdf SSA-3369-BK(current)	IC Document

IC Title:

Work History Report

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 416.912 20 CFR 404.1560 20 CFR 404.1565 20 CFR 404.1512 20 CFR 416.965 20 CFR 416.960

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	SSA-3369	Work History Report	SSA-3369-BK- (revised).pdf	No	Paper Only
Other-Revised Privacy Act Statement			Privacy Act Statement Revised.doc	No	Paper Only
Other-Revised PRA			Revised PRA.doc	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,553,900

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	Previously Approved
Annual Number of Responses for this IC	1,553,900	1,553,900
Annual IC Time Burden (Hours)	1,553,900	1,553,900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3369-BK(current)	SSA-3369-BK (current).pdf	05/15/2017

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