Discrimination Complaint Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0585 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-437 Discrimination Complaint Form Form and Instruction
SSA-437 - Revised Privacy Act Statement.pdf Other-Privacy Act Statement (revised
SSA-437 Discrimination Complaint Form SSA-437-BK - Revised.pdf Form and Instruction
SSA-437 (current).pdf Current SSA-437 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Discrimination Complaint Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-437	Discrimination Complaint Form	SSA-437-BK - Revised.pdf		Yes	No	Fillable Printable
Other-Privacy Act Statement (revised)			SSA-437 - Revised Privacy Act Statement.pdf		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 255	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	255	255
Annual IC Time Burden (Hours)	255	255
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-437	SSA-437 (current).pdf	05/22/2019

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