Disability Report - Adult, (Fillable PDF)

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⚠️ Notice: This information collection may be referencing outdated material.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, (Fillable PDF) Form and Instruction
SSA-3368 Disability Report - Adult SSA-3368-BK Revised (2015 Mock-up).pdf Form and Instruction
ssa-3368 Current Version.pdf SSA-3368-BK -- Current Version IC Document

Information Collection (IC) Details

IC Title:	Disability Report - Adult, (Fillable PDF)	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 416.912 20 CFR 404.1512

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	SSA-3368-BK Revised (2015 Mock-up).pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,571	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	7,571	-21,501	29,072
Annual IC Time Burden (Hours)	11,357	-17,715	29,072
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3368-BK -- Current Version	ssa-3368 Current Version.pdf	04/29/2015

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