Information Collection

Workers' Compensation/Public Disability Benefit Questionnaire

IC 9165 under ICR 201707-0960-005 · OMB 0960-0247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA- 546 - MCS Screens.pdf	Other-Inernal Intranet Screens

IC Title:

Workers' Compensation/Public Disability Benefit Questionnaire

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 404.408

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
Other-Inernal Intranet Screens					Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 248,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	248,000	248,000
Annual IC Time Burden (Hours)	62,000	62,000
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.

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