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

Disability Report-Appeal

Documents and Forms

Document Name Document Type
Form SSA-3441 Disability Report-Appeal - SSA-3441 (Paper Version) Form and Instruction
SSA-3441 Disability Report--Appeal SSA-3441 (revised).pdf Form and Instruction
SSA-3441 (current).pdf SSA-3441 (current) IC Document

Information Collection (IC) Details

IC Title:	Disability Report-Appeal - SSA-3441 (Paper Version)	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 416.1416(c) 20 CFR 404.916(c) 20 CFR 405 20 CFR 422.140 20 CFR 404.1512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3441	Disability Report--Appeal	SSA-3441 (revised).pdf		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 %

	Requested	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

Title	Document	Date Uploaded
SSA-3441 (current)	SSA-3441 (current).pdf	10/22/2024

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