Information Collection

Workers' Compensation/Public Disability Benefit Questionnaire

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-546 Workers’ Compensation / Public Disability Benefit Questionnaire Workers' Compensation/Public Disability Benefit Questionnaire	Form
SSA- 546 - MCS Screens.pdf	Other-Inernal Intranet Screens
SSA- 546 - MCS Screens.pdf	Other-Inernal Intranet Screens
SSA-546 Workers’ Compensation / Public Disability Benefit Questi SSA-546 (revised).pdf	Form
SSA-546 Workers’ Compensation / Public Disability Benefit Questi SSA-546 (revised).pdf	Form
SSA-546 (current).pdf Workers’ Compensation / Public Disability Benefit Questionnaire	IC Document
SSA-546 (current).pdf Workers’ Compensation / Public Disability Benefit Questionnaire	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.408

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
Other-Inernal Intranet Screens					Yes	Yes	Fillable Fileable Signable
Form	SSA-546				Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 248,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	248,000	248,000
Annual IC Time Burden (Hours)	186,000	186,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Workersâ Compensation / Public Disability Benefit Questionnaire		01/21/2025

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

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