Disability Report - Adult, (Paper Version)

Disability Report - Adult

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SSA-3368 Disability Report - Adult, (Paper Version) Form and Instruction
SSA-3368 Disability Report - Adult -- Revised Version SSA-3368 - Revised Version (mocked-up form).pdf Form and Instruction
SSA-3368-BK - Current Version.pdf SSA-3368-BK -- Current Version IC Document

Information Collection (IC) Details

IC Title:	Disability Report - Adult, (Paper Version)	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 404.1512 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-3368	Disability Report - Adult -- Revised Version	SSA-3368 - Revised Version (mocked-up form).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: 29,072	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	29,072	6,122	22,950
Annual IC Time Burden (Hours)	29,072	6,122	22,950
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3368-BK -- Current Version	SSA-3368-BK - Current Version.pdf	05/18/2012

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