Information Collection

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

IC 234805 under ICR 202002-0960-008 · OMB 0960-0813.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3441 Disability Report-Appeal 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

View Information Collection (IC)

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:

table that charts list of 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

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: 760,620

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	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

table that charts IC Documents
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.