Information Collection

Request for Change in Time/Place of Disability Hearing

IC 9228 under ICR 202201-0960-003 · OMB 0960-0348.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0348 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-769 Request for Change in Time/Place of Disability Hearing Form
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
SSA-769 Request for Change in Time/Place of Disability Hearing SSA-769 - Revised.pdf Form
SSA-769 - Current.pdf SSA-769 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Change in Time/Place of Disability Hearing	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.914(c)(2) 20 CFR 416.1414(c)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-769	Request for Change in Time/Place of Disability Hearing	SSA-769 - Revised.pdf		No		Fillable Printable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 41,440	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	41,440	33,957	7,483
Annual IC Time Burden (Hours)	5,525	4,527	998
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-769 - Current	SSA-769 - Current.pdf	05/17/2022

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