0960-0144 - SSA-3441 - Disability Report-Appeal

Removing Inability to Communicate in English as an Education Category

Documents and Forms

Document Name Document Type
Form SSA-3441 0960-0144 - SSA-3441 - Disability Report-Appeal Form
i3441 Screens - Updated.pdf Other-i3441 Screens
3441 EDCS Screens.pdf Other-3441 EDCS Screens
SSA-3441 Disability Report-Appeal SSA-3441 - Revised Version.pdf Form
Supporting Statement - 0144 (for RIN 0960-AH86).docx Supporting Statement - 0144 (for RIN 0960-AH86) IC Document
Addendum - 0144 (for RIN 0960 AH86).docx Addendum - 0144 (for RIN 0960 AH86) IC Document
SSA-3441 - Current Version.pdf SSA-3441 - Current Version IC Document

Information Collection (IC) Details

IC Title:	0960-0144 - SSA-3441 - Disability Report-Appeal	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.912 20 CFR 404.1512 20 CFR 404.916(c) 20 CFR 416.1416(c) 20 CFR 422.140 20 CFR 404.1713 20 CFR 416.1513 20 CFR 404.1740(b)(4) 20 CFR 416.1540(b)(4) 20 CFR 405, Subpart C (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3441	Disability Report-Appeal	SSA-3441 - Revised Version.pdf	No		Paper Only
Other-i3441 Screens			i3441 Screens - Updated.pdf	Yes	Yes	Fillable Fileable
Other-3441 EDCS Screens			3441 EDCS Screens.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 760,620	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	760,620	760,620
Annual IC Time Burden (Hours)	520,346	520,346
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement - 0144 (for RIN 0960-AH86)	Supporting Statement - 0144 (for RIN 0960-AH86).docx	02/25/2020
Addendum - 0144 (for RIN 0960 AH86)	Addendum - 0144 (for RIN 0960 AH86).docx	02/25/2020
SSA-3441 - Current Version	SSA-3441 - Current Version.pdf	01/31/2019

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