Information Collection

Disability Report - Adult, (Paper Version)

IC 9548 under ICR 201302-0960-004 · OMB 0960-0579.

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Report - Adult, (Paper Version)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 416.912

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 -- Revised Version	SSA-3368 - Revised Version (mocked-up form).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: 29,072	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	29,072	29,072
Annual IC Time Burden (Hours)	29,072	29,072
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3368-BK -- Current Version	SSA-3368-BK - Current Version.pdf	05/18/2012

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