Information Collection

Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview

IC 9455 under ICR 201904-0960-016 · OMB 0960-0542.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0542 can be found here:

2024-12-13 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3375-BK Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)	Form
Form SSA-3375-BK Function Report-Child Birth to 1st Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview	Form
Form SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview	Form
Form SSA-3377-BK Function Report-Child Age 3 to 6th Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview	Form
Form SSA-3378-BK Function Report-Child Age 6 to 12th Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview	Form
Form SSA-3379-BK Function Report-Child Age 12 to 18th Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview	Form
Revised PA Statement.pdf	Other-Revised Privacy Act Statement
Revised PA Statement.pdf	Other-Revised Privacy Act Statement
SSA-3375-BK Function Report-Child Birth to 1st Birthday SSA-3375-BK - Revised.pdf	Form
SSA-3375-BK Function Report-Child Birth to 1st Birthday SSA-3375-BK - Revised.pdf	Form
SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday SSA-3376-BK - Revised.pdf	Form
SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday SSA-3376-BK - Revised.pdf	Form
SSA-3377-BK Function Report-Child Age 3 to 6th Birthday SSA-3377-BK - Revised.pdf	Form
SSA-3377-BK Function Report-Child Age 3 to 6th Birthday SSA-3377-BK - Revised.pdf	Form
SSA-3378-BK Function Report-Child Age 6 to 12th Birthday SSA-3378-BK - Revised.pdf	Form
SSA-3378-BK Function Report-Child Age 6 to 12th Birthday SSA-3378-BK - Revised.pdf	Form
SSA-3379-BK Function Report-Child Age 12 to 18th Birthday SSA-3379-BK - Revised.pdf	Form
SSA-3379-BK Function Report-Child Age 12 to 18th Birthday SSA-3379-BK - Revised.pdf	Form
SSA-3375-BK - Current.pdf Current SSA-3375	IC Document
SSA-3375-BK - Current.pdf Current SSA-3375	IC Document
SSA-3376-BK - Current.pdf Current SSA-3376	IC Document
SSA-3376-BK - Current.pdf Current SSA-3376	IC Document
SSA-3377-BK - Current.pdf Current SSA-3377	IC Document
SSA-3377-BK - Current.pdf Current SSA-3377	IC Document
SSA-3378-BK - Current.pdf Current SSA-3378	IC Document
SSA-3378-BK - Current.pdf Current SSA-3378	IC Document
SSA-3379-BK - Current.pdf Current SSA-3379	IC Document
SSA-3379-BK - Current.pdf Current SSA-3379	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview

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 416.912 20 CFR 416.924a (a) (2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3375-BK	Yes	No	Fillable Printable
Form	SSA-3376-BK	Yes	No	Fillable Printable
Form	SSA-3377-BK	Yes	No	Fillable Printable
Form	SSA-3378-BK	Yes	No	Fillable Printable
Form	SSA-3379-BK	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement for Forms SSA-3375 - SSA-3379		No		Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 521,100

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	521,100	-10,900	532,000
Annual IC Time Burden (Hours)	173,700	-3,633	177,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3375		07/16/2019
Current SSA-3376		07/16/2019
Current SSA-3377		07/16/2019
Current SSA-3378		07/16/2019
Current SSA-3379		07/16/2019

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

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