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Federal forms, ICRs, and supporting documents

Information Collection

Workers' Compensation/Public Disability Benefit Questionnaire

IC 9165 under ICR 202501-0960-007 · OMB 0960-0247.

Documents and Forms
Document Name
Document Type
Other-Inernal Intranet Screens
Other-Inernal Intranet Screens
Form
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Workers' Compensation/Public Disability Benefit Questionnaire
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.408

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Inernal Intranet Screens SSA- 546 - MCS Screens.pdf Yes Yes Fillable Fileable Signable
Form SSA-546 Workers’ Compensation / Public Disability Benefit Questionnaire SSA-546 (revised).pdf Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

248,000 0
   
Individuals or Households
 
   100 %

  Approved 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 248,000 0 0 0 0 248,000
Annual IC Time Burden (Hours) 186,000 0 0 0 0 186,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Workers’ Compensation / Public Disability Benefit Questionnaire SSA-546 (current).pdf 01/21/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.