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⚠️ Notice: This information collection may be referencing outdated material.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
Sample Title II Adverse Action Notice (revised).pdf Other-Notice
Sample Title XVI Adverse Action Notice (revised).pdf Other-Notice
SSA-821-BK Work Activity Report- Employee SSA-82-BK (revised).pdf Form
SSA-82-BK (current).pdf SSA-821-BK (current) IC Document
Sample Title II Adverse Action Notice (current).pdf Sample Title II Adverse Action Notice IC Document
Sample Title XVI Adverse Action Notice (current).pdf Sample Title XVI Adverse Action Notice 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 404.1571-1576 20 CFR 416.971-976 20 CFR 404.1520(b) 20 CFR 404.1584-1593

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-82-BK (revised).pdf	Yes	No	Fillable Printable
Other-Notice			Sample Title II Adverse Action Notice (revised).pdf	No		Paper Only
Other-Notice			Sample Title XVI Adverse Action Notice (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: 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-82-BK (current).pdf	08/27/2020
Sample Title II Adverse Action Notice	Sample Title II Adverse Action Notice (current).pdf	08/27/2020
Sample Title XVI Adverse Action Notice	Sample Title XVI Adverse Action Notice (current).pdf	08/27/2020

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