Workers Compensation Public Disability Benefit Questionnaire

Workers' Compensation/Public Disability Benefit Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0247 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-546 Workers Compensation Public Disability Benefit Questionnaire Form
SSA-546 Workers compensation Public Disability Benefit Questionn SSA-546 (revised).pdf Form
SSA-546.pdf SSA-546 (current) IC Document

Information Collection (IC) Details

IC Title:	Workers Compensation Public Disability Benefit Questionnaire	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-546	Workers compensation Public Disability Benefit Questionnaire	SSA-546 (revised).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: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-546 (current)	SSA-546.pdf	11/29/2011

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