Information Collection

0960-0578 SSA-3369 (Paper Form) 410.1560; 404.1565; 416.960; 416.965

IC 262364 under ICR 202309-0960-005 · OMB 0960-0834.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0834 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3369 0960-0578 SSA-3369 (Paper Form) 410.1560; 404.1565; 416.960; 416.965	Form and Instruction
SSA-3369 Work History Report SSA-3369 (Revised for PRW NPRM).pdf www.ssa.gov	Form and Instruction
SSA-3369 Work History Report SSA-3369 (Revised for PRW NPRM).pdf www.ssa.gov	Form and Instruction
SSA-3369 (Current).pdf Current SSA-3369	IC Document
SSA-3369 (Current).pdf Current SSA-3369	IC Document

IC Title:

0960-0578 SSA-3369 (Paper Form) 410.1560; 404.1565; 416.960; 416.965

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.960 20 CFR 404.1560 20 CFR 404.1565 20 CFR 410.1560

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	Work History Report	SSA-3369 (Revised for PRW NPRM).pdf	www.ssa.gov	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: 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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,553,900	1,553,900
Annual IC Time Burden (Hours)	1,035,933	1,035,933
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-3369	SSA-3369 (Current).pdf	10/02/2023

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