Information Collection

c) 20 CFR 411.200(b) - SSA-1375

IC 184457 under ICR 202401-0960-002 · OMB 0960-0644.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375	Form
SSA-1375 Ticket to Work Progress Review Form SSA-1375 (revised).pdf	Form
SSA-1375 Ticket to Work Progress Review Form SSA-1375 (revised).pdf	Form
SSA-1375 (current).pdf SSA-1375 (current)	IC Document
SSA-1375 (current).pdf SSA-1375 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 411.200(b)

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-1375	Ticket to Work Progress Review Form	SSA-1375 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 179

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	Previously Approved
Annual Number of Responses for this IC	179	179
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1375 (current)	SSA-1375 (current).pdf	12/07/2023

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