OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview

IC 9455 under ICR 202407-0960-008 · OMB 0960-0542.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form SSA-3375-BK
Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview		 Form
Form SSA-3375-BK
Function Report-Child Birth to 1st Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview		 Form
Form SSA-3376-BK
Function Report-Child Age 1 to 3rd Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview		 Form
Form SSA-3377-BK
Function Report-Child Age 3 to 6th Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview		 Form
Form SSA-3378-BK
Function Report-Child Age 6 to 12th Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview		 Form
Form SSA-3379-BK
Function Report-Child Age 12 to 18th Birthday Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview		 Form
Revised PA Statement.pdf Other-Revised Privacy Act Statement
SSA-3375-BK Function Report-Child Birth to 1st Birthday
SSA-3375-BK - Revised.pdf 		Form
SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday
SSA-3376-BK - Revised.pdf 		Form
SSA-3377-BK Function Report-Child Age 3 to 6th Birthday
SSA-3377-BK - Revised.pdf 		Form
SSA-3378-BK Function Report-Child Age 6 to 12th Birthday
SSA-3378-BK - Revised.pdf 		Form
SSA-3379-BK Function Report-Child Age 12 to 18th Birthday
SSA-3379-BK - Revised.pdf 		Form
SSA-3375-BK - Current.pdf
Current SSA-3375		IC Document
SSA-3376-BK - Current.pdf
Current SSA-3376		IC Document
SSA-3377-BK - Current.pdf
Current SSA-3377		IC Document
SSA-3378-BK - Current.pdf
Current SSA-3378		IC Document
SSA-3379-BK - Current.pdf
Current SSA-3379		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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-3375-BK Function Report-Child Birth to 1st Birthday SSA-3375-BK - Revised.pdf Yes No Fillable Printable
Form SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday SSA-3376-BK - Revised.pdf Yes No Fillable Printable
Form SSA-3377-BK Function Report-Child Age 3 to 6th Birthday SSA-3377-BK - Revised.pdf Yes No Fillable Printable
Form SSA-3378-BK Function Report-Child Age 6 to 12th Birthday SSA-3378-BK - Revised.pdf Yes No Fillable Printable
Form SSA-3379-BK Function Report-Child Age 12 to 18th Birthday SSA-3379-BK - Revised.pdf Yes No Fillable Printable
Other-Revised Privacy Act Statement for Forms SSA-3375 - SSA-3379 Revised PA Statement.pdf No   Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 -521,100 0 0 521,100
Annual IC Time Burden (Hours) 0 0 -173,700 0 0 173,700
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Current SSA-3375 SSA-3375-BK - Current.pdf 07/16/2019
Current SSA-3376 SSA-3376-BK - Current.pdf 07/16/2019
Current SSA-3377 SSA-3377-BK - Current.pdf 07/16/2019
Current SSA-3378 SSA-3378-BK - Current.pdf 07/16/2019
Current SSA-3379 SSA-3379-BK - Current.pdf 07/16/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.