Disability Report - Adult, (Fillable PDF)

Disability Report - Adult

Documents and Forms

Document Name Document Type
Form SSA-3368 Disability Report - Adult, (Fillable PDF) Form and Instruction
Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
SSA-3368 Disability Report - Adult SSA-3368-BK - Revised.pdf Form and Instruction
SSA-3368-BK - Current.pdf SSA-3368-BK - Current IC Document

Information Collection (IC) Details

IC Title:	Disability Report - Adult, (Fillable PDF)	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 404.1512 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3368	Disability Report - Adult	SSA-3368-BK - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA and PRA Statements			Revised PA & PRA Statements.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,045	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,045	-1,526	7,571
Annual IC Time Burden (Hours)	9,068	-2,289	11,357
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3368-BK - Current	SSA-3368-BK - Current.pdf	10/19/2021

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