Information Collection

Report of Adult Functioning-Employer

IC 221156 under ICR 201706-0960-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 SSA-3385 (revised).pdf	Form
SSA-3385 (current).pdf SSA-3385-BK (current)	IC Document

IC Title:

Report of Adult Functioning-Employer

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	SSA-3385 (revised).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: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
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
SSA-3385-BK (current)	SSA-3385 (current).pdf	07/05/2017

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