Disability Report, Adult

ICR 199802-0960-005

OMB: 0960-0141

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
9122 Migrated
ICR Details
0960-0141 199802-0960-005
Historical Active 199710-0960-005
SSA
Disability Report, Adult
Extension without change of a currently approved collection   No
Regular
Approved without change 04/15/1998
Retrieve Notice of Action (NOA) 02/23/1998
  Inventory as of this Action Requested Previously Approved
04/30/2001 04/30/2001 04/30/1998
36,500 0 36,500
18,250 0 18,250
0 0 0

The information collected on form SSA-3368-BK is needed for the determinations of disability by the State Disability Determinations Services. This version of the form will be used in those SSA offices and State DDS offices that are piloting SSA's reengineered disability system. The information will be used to develop medical evidence and to assess the alleged disability. The respondents are applicants for disability benefits.

None
None


No

1
IC Title Form No. Form Name
Disability Report, Adult SSA-3368-BK

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 36,500 36,500 0 0 0 0
Annual Time Burden (Hours) 18,250 18,250 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/23/1998


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