Disability Report - Adult, (Internet Version)

Disability Report - Adult

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0579 can be found here:

Documents and Forms

Document Name Document Type
i3368 screenshots.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp Other-SSA-3368 (Internet)
PAS 0579 (revised).docx Other-Revised Privacy Act Statement

Information Collection (IC) Details

IC Title:	Disability Report - Adult, (Internet Version)	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 404.1512 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSA-3368 (Internet)			i3368 screenshots.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable
Other-Revised Privacy Act Statement			PAS 0579 (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,060,360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,060,360	1,060,360
Annual IC Time Burden (Hours)	1,590,540	1,590,540
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.