Information Collection

Child-Care Dropout Questionnaire

IC 9367 under ICR 201903-0960-006 · OMB 0960-0474.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0474 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4162 Child-Care Dropout Questionnaire	Form
SSA-4162 - MCS Screens.pdf	Other-Internal MCS Screens
Revised PA Statement.pdf	Other-Revised Privacy Act Statement
SSA-4162 Child-Care Dropout Questionnaire SSA-4162 - Revised.pdf	Form
SSA-4162 - Current.pdf SSA-4162 - Current	IC Document

IC Title:

Child-Care Dropout 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 404.211(e)(4)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4162	Child-Care Dropout Questionnaire	SSA-4162 - Revised.pdf	No		Paper Only
Other-Internal MCS Screens			SSA-4162 - MCS Screens.pdf	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement			Revised PA Statement.pdf	No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4162 - Current	SSA-4162 - Current.pdf	05/29/2019

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