Information Collection

Disability Report - Adult, (Fillable PDF)

IC 9548 under ICR 202501-0960-002 · OMB 0960-0579.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0579 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3368 Disability Report - Adult, (Fillable PDF)	Form and Instruction
Form SSA-3368 Disability Report - Adult Disability Report - Adult, (Fillable PDF)	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-3368 Disability Report - Adult SSA-3368-BK - Revised.pdf	Form and Instruction
SSA-3368 Disability Report - Adult SSA-3368-BK - Revised.pdf	Form and Instruction
SSA-3368-BK - Current.pdf SSA-3368-BK - Current	IC Document
SSA-3368-BK - Current.pdf SSA-3368-BK - Current	IC Document

IC Title:

Disability Report - Adult, (Fillable PDF)

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 404.1512 20 CFR 416.912

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-3368				Yes	No	Fillable Printable
Other-Revised PA and PRA Statements					Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,045

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	6,045	6,045
Annual IC Time Burden (Hours)	9,068	9,068
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3368-BK - Current		10/19/2021

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

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