Information Collection

Disability Report-Appeal - SSA-3441 (Paper Version)

IC 43698 under ICR 202410-0960-002 · OMB 0960-0144.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3441 Disability Report-Appeal - SSA-3441 (Paper Version)	Form and Instruction
Form SSA-3441 Disability Report--Appeal Disability Report-Appeal - SSA-3441 (Paper Version)	Form and Instruction
SSA-3441 Disability Report--Appeal SSA-3441 (revised).pdf	Form and Instruction
SSA-3441 Disability Report--Appeal SSA-3441 (revised).pdf	Form and Instruction
SSA-3441 (current).pdf SSA-3441 (current)	IC Document
SSA-3441 (current).pdf SSA-3441 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.912 20 CFR 404.916(c) 20 CFR 416.1416(c) 20 CFR 405 20 CFR 422.140 20 CFR 404.1512

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-3441				No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,645

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24,645	2,089	22,556
Annual IC Time Burden (Hours)	20,538	3,621	16,917
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3441 (current)		10/22/2024

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

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