View Information Collection (IC)

View Information Collection (IC)

IC Title:	Work History Report	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 404.1560 20 CFR 404.1565 20 CFR 404.1512 20 CFR 416.965 20 CFR 416.960

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3369	Work History Report	SSA-3369-BK- (revised).pdf		No		Paper Only
Other-Revised Privacy Act Statement			Privacy Act Statement Revised.doc		No		Paper Only
Other-Revised PRA			Revised PRA.doc		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,553,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1,553,900	0	0	0	0	1,553,900
Annual IC Time Burden (Hours)	1,553,900	0	0	0	0	1,553,900
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3369-BK(current)	SSA-3369-BK (current).pdf	05/15/2017

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