Disability Report - Adult, (Internet Version)

Disability Report - Adult

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Disability Report - Adult, (Internet Version)	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
Other-i3368 (Internet)				https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 989,361	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	989,361	0	989,361
Annual IC Time Burden (Hours)	1,319,148	-164,894	1,484,042
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Previously Approved Screens for the i3368 (prior to implementation of the PRW FR)		08/15/2025

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

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