Information Collection

Health IT Partner Assessment - SSA-680

IC 201618 under ICR 202109-0960-002 · OMB 0960-0798.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0798 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-680 Health IT Partner Assessment - SSA-680	Form
SSA-680 Health IT Partner Assessment SSA-680 (revised).xlsx	Form
SSA-680 Health IT Partner Assessment SSA-680 (revised).xlsx	Form
SSA-680 (current).xlsx Current SSA-680	IC Document
SSA-680 (current).xlsx Current SSA-680	IC Document

IC Title:

Health IT Partner Assessment - SSA-680

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	SSA-680	Health IT Partner Assessment	SSA-680 (revised).xlsx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30	0	30
Annual IC Time Burden (Hours)	1,200	1,050	150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-680	SSA-680 (current).xlsx	09/13/2021

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