To view the form, go to SSA-437–BK
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number.
Time it takes to complete this form
We estimate that it will take you about one hour to provide the information. This includes the time it takes to read the instructions, gather the facts and complete the forms.
Uses of personal information for investigations
The information collection is authorized by 5 U.S.C. §301; 29 U.S.C. §791 et. seq.; 42 U.S.C.§§902(a)(5), 1305 note. Those statutes require the agency not to discriminate on the basis of disability and authorize the Commissioner establish policies to prohibit SSA and SSA employees from discriminating based upon race, color national origin, sex, age, religion, or retaliation in any program or activity conducted by SSA.
There are two federal laws governing personal information given to all Federal agencies, including the Office of the Deputy Commissioner for Civil Rights and Equal Opportunity (OCREO):
The Privacy Act of 1974, (U.S.C. Sec. 522a); and
The Freedom of Information Act, (5 U.S.C. Sec. 522).
The Privacy Act protects individuals from misuse of personal information held by the Federal government. The law applies to records that are kept and that can be located by the name, social security number, or other personal identification system.
Personal information will be used for authorized civil rights activities and other Privacy Act routine uses. Generally, OCREO will not release information unless the person who supplied the information submits a written consent, or unless release is required under the Freedom of Information Act or other Federal statute or regulation. However, OCREO can refer complaints to other Federal agencies, such as the Department of Justice, the Department of Labor and the Equal Employment Opportunity Commission, without the person's prior consent. This authority is provided under the “routine use” exception of the Privacy Act.
Information submitted to OCREO may also be given to other government agencies, such as the Department of Justice, when as SSA components has violated civil rights laws or regulations.
A person cannot be required to give personal information to OCREO, and no sanctions will be imposed on person who deny our request. However, if
cannot get information needed to investigate allegations of discrimination, it may have to close the
The Freedom of Information Act (FOIA) gives the public the right of access to files and records of the Federal government. With some exceptions, the Social Security Administration must honor FOIA request, though our policy is to do so without releasing a person's name or other personal identification. SSA is generally not required to release documents if the release would interfere with SSA's ability to complete its work; as, for example, during an investigation or enforcement proceeding. Also, any Federal agency may refuse a request for files or records if the release would be an unnecessary invasion of an individual's privacy.