Work Activity Report--Employee

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0059 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-821-BK Work Activity Report--Employee Form
Revised PA Statement.pdf Other-Revised PA Statement
Work CDR Sample Notice.docx Other-Work CDR Sample Notice
SSA-821-BK Work Activity Report- Employee SSA-821-BK - Revised.pdf Form
SSA-821-BK - Current.pdf SSA-821-BK (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Work Activity Report--Employee	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 404.1584-1593 20 CFR 404.1571-1576 20 CFR 416.971-976 20 CFR 404.1520(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-821-BK	Work Activity Report- Employee	SSA-821-BK - Revised.pdf	Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf	No		Paper Only
Other-Work CDR Sample Notice			Work CDR Sample Notice.docx	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300,000	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	300,000	300,000
Annual IC Time Burden (Hours)	150,000	150,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-821-BK (current)	SSA-821-BK - Current.pdf	08/15/2018

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