Information Collection

Work History Report

IC 9542 under ICR 202009-0960-011 · OMB 0960-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3369 Work History Report	Form and Instruction
Form SSA-3369 Work History Report Work History Report	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-3369 Work History Report SSA-3369-BK - Revised.pdf	Form and Instruction
SSA-3369 Work History Report SSA-3369-BK - Revised Mockup.pdf	Form and Instruction
SSA-3369-BK - Current.pdf SSA-3369-BK - Current	IC Document
SSA-3369-BK - Current.pdf SSA-3369-BK - Current	IC Document

IC Title:

Work History Report

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 404.1560 20 CFR 416.912 20 CFR 404.1565 20 CFR 404.1512 20 CFR 416.965 20 CFR 416.960

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3369				No		Fillable Printable
Other-Revised PA & PRA Statements					No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,553,900

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	1,553,900	0	1,553,900
Annual IC Time Burden (Hours)	2,952,410	1,398,510	1,553,900
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3369-BK - Current		12/04/2020

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].