SSA-3373 (0960-0681) supporting statement

SUPPORTING STATEMENT FOR FORM SSA-3373-BK

FUNCTION REPORT-ADULT

20 CFR 404.1512 and 20 CFR 416.912

OMB No. 0960-0681

A. Justification

1. Sections 205(a), 223(d), and 1631(e) (1) of the Social Security Act mandate that applicants and continuing claimants for disability benefits must provide medical evidence and any other proof that the Social Security Administration (SSA) requires to prove their disability. Sections 20 CFR 404.1512 and 20 CFR 416.912 of the Code of Federal Regulations provide more detailed requirements, stating that disability applicants and claimants must provide evidence of age, education and training, work experience, daily activities, efforts to work, and any other evidence showing how his or her impairment(s) affects the ability to work. A collection instrument is needed to gather this required information. Form SSA-3371-BK, the Function Report-Adult, is the instrument used to accomplish this for adult disability applicants and claimants.

2. The information collected by form SSA-3373 is used by the State Disability Determination Services (DDS) to document how disability applicants’ or claimants’ alleged disabilities impact their ability to function. This information, together with medical evidence, forms the evidentiary basis upon which SSA will make a determination of whether disability benefits should be granted or should continue.

3. Form SSA-3373-BK has not currently been made available in an electronic format under the Agency’s Government Paperwork Elimination Act plan because SSA has had to devote its limited resources to other, more urgent electronic projects, such as the new Medicare Part D online application. However, SSA plans to evaluate this form for electronic conversion within the next few years.

4. The nature of the information being collected and the manner in which it is collected preclude duplication. There is no other collection instrument used by SSA that collects data similar to that collected here.

5. This collection does not impact small businesses or other small entities.

5. If this information were not collected, it would be impossible to determine whether disability applicants or current recipients were truly disabled, and SSA would not be able to discharge its mandate to pay benefits to the disabled. Since the form is only completed once for an initial application and on an occasional basis if a disability recipient is selected for a reconsideration or participates in an appeals hearing, the information cannot be collected less frequently.

There are no technical or legal obstacles that prevent burden reduction.

5. There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.

5. The 60-day advance Federal Register Notice was published on May 26, 2006 at 71 FR 30464, and no public comments were received. The 30-day Federal Register Notice was published on August 8, 2006, at 71 FR 45090. We will notify OMB if any public comments are submitted in response to that notice.

There have been no outside consultations with the public.

5. SSA provides no payment or gifts to the respondents except for the actual disability payments (if one qualifies for them).

5. The information requested is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552a (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

5. The information collection does not contain any questions of a sensitive nature.

5. Form SSA-3373-BK is completed by approximately 4,005,367 respondents with a response time of 60 minutes. The total burden is therefore 4,005,367 burden hours per annum. The total burden is reflected as burden hours, and no separate cost burden has been calculated.

5. There is no known cost burden to the respondents.

5. The annual cost to the Federal Government is approximately $37,009,591. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

5. In 2003, when this form last underwent OMB clearance, its estimated completion time for form SSA-3373-BK was 30 minutes. In the three years since that time, SSA has received numerous comments from members of the public stating that 30 minutes was insufficient to complete this form. Because of these comments, and because of the questions we have added to the form (see Addendum), we have increased the estimated completion time to 60 minutes. This causes an increase in the annual burden from 2,002,684 to 4,005,367 hours.

5. The results of the information collection will not be published.

5. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

5. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collection of Information Employing Statistical Methods

Statistical methods are not used for this information collection.

SSA-3371-BK 2/6/2021

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