Work History Report

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0578 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3369 Work History Report Form and Instruction
SSA-3369 Work History Report SSA-3369 final.pdf Form and Instruction
SSA-3369-BK.pdf Work History Report (current version) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Work History Report	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 404.1560 20 CFR 404.1565 20 CFR 404.1512 20 CFR 416.965 20 CFR 416.960 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3369	Work History Report	SSA-3369 final.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,090,346	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,090,346	1,069,346	21,000
Annual IC Time Burden (Hours)	1,090,346	1,069,346	21,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Work History Report (current version)	SSA-3369-BK.pdf	11/10/2010

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