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
Document Name
Document Type
Form
Other-Revised Privacy Act Statement
Form
Form
Form
Form
Form
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview
 
No Removed
 
Required to Obtain or Retain Benefits
 
20 CFR 416.912 20 CFR 416.924a (a) (2)

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

Income Security General Retirement and Disability

 

521,100 0
   
Individuals or Households
 
   0 %

  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

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.