Information Collection

Work History Report

IC 9542 under ICR 200702-0960-002 · OMB 0960-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0578 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3369-BK Work History Report Form
SSA-3369-BK Work History Report ssa-3369bk revision.pdf Form

Information Collection (IC) Details

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: Voluntary

CFR Citation: 20 CFR 416.912 20 CFR 404.1512 20 CFR 404.1560 20 CFR 404.1565 20 CFR 416.960 20 CFR 416.965

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3369-BK	Work History Report	ssa-3369bk revision.pdf		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: 21,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,000	-850,000	871,000
Annual IC Time Burden (Hours)	21,000	-850,000	871,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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