Information Collection

0960-0579 - SSA-3368 - Disability Report-Adult

IC 234806 under ICR 201901-0960-009 · OMB 0960-0813.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0813 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3368 0960-0579 - SSA-3368 - Disability Report-Adult Form
EDCS 3368 Screenshots.pdf Other-EDCS Screens
i3368 screenshots.pdf Other-i3368 Screens
SSA-3368 Disability Report - Adult SSA-3368 - Revised Version.pdf Form
Supporting Statement - 0579 (for RIN 0960-AH86).docx Supporting Statement - 0579 (for RIN 0960-AH86) IC Document
Addendum - 0579 (for RIN 0960 AH86).docx Addendum - 0579 (for RIN 0960 AH86) IC Document
SSA-3368 - Current Version.pdf SSA-3368 - Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	0960-0579 - SSA-3368 - Disability Report-Adult	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3368	Disability Report - Adult	SSA-3368 - Revised Version.pdf	No		Paper Only
Other-EDCS Screens			EDCS 3368 Screenshots.pdf	Yes	Yes	Fillable Fileable Signable
Other-i3368 Screens			i3368 screenshots.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,552,162	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	3,552,162	3,552,162
Annual IC Time Burden (Hours)	5,328,244	5,328,244
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement - 0579 (for RIN 0960-AH86)	Supporting Statement - 0579 (for RIN 0960-AH86).docx	02/01/2019
Addendum - 0579 (for RIN 0960 AH86)	Addendum - 0579 (for RIN 0960 AH86).docx	01/31/2019
SSA-3368 - Current Version	SSA-3368 - Current Version.pdf	01/31/2019

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