Information Collection

Request for Change in Time/Place of Disability Hearing

IC 9228 under ICR 202201-0960-003 · OMB 0960-0348.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0348 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-769 Request for Change in Time/Place of Disability Hearing	Form
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-769 Request for Change in Time/Place of Disability Hearing SSA-769 - Revised.pdf	Form
SSA-769 - Current.pdf SSA-769 - Current	IC Document

IC Title:

Request for Change in Time/Place of Disability Hearing

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.914(c)(2) 20 CFR 416.1414(c)(2)

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-769	Request for Change in Time/Place of Disability Hearing	SSA-769 - Revised.pdf		No		Fillable Printable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 41,440

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	41,440	33,957	7,483
Annual IC Time Burden (Hours)	5,525	4,527	998
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-769 - Current	SSA-769 - Current.pdf	05/17/2022

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