Information Collection

Disability Report - Adult, (Internet Version)

IC 179420 under ICR 202501-0960-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
i3368 Screenshots.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp Other-i3368 (Internet)
i3368 Screenshots.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp Other-i3368 (Internet)
Revised Save and Exit Screens for i3368.pdf www.ssa.gov Other-Revised Internet Screens
Revised Save and Exit Screens for i3368.pdf www.ssa.gov Other-Revised Internet Screens
Current Save and Exit Screens for i3368.pdf Current Save and Exit Screens for the i3368 IC Document
Current Save and Exit Screens for i3368.pdf Current Save and Exit Screens for the i3368 IC Document

Information Collection (IC) Details

View Information Collection (IC)

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)			i3368 Screenshots.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable
Other-Revised Internet Screens			Revised Save and Exit Screens for i3368.pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	989,361	989,361
Annual IC Time Burden (Hours)	1,484,042	1,484,042
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current Save and Exit Screens for the i3368	Current Save and Exit Screens for i3368.pdf	01/08/2025

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