Pain Report - Child, 20 CFR 416.912 & 404.1512

Forms and Documents

Document Name	Status
Form SSA-3371-BK Pain Report - Child, 20 CFR 416.912 & 404.512 Form	Modified
Addendum to Supporting Statement - SSA-3371BK.doc Supplementary Document	2007-02-22
SSA-3371BK Supporting Statement 090806.doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
9452	Pain Report - Child, 20 CFR 416.912 & 404.512 Form	Modified

ICR Details

OMB Control No: 0960-0540	ICR Reference No: 200612-0960-007
Status: Historical Active	Previous ICR Reference No: 200403-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Pain Report - Child, 20 CFR 416.912 & 404.1512
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/01/2007
	Date Received in OIRA: 02/26/2007
Terms of Clearance: Approved consistent with SSA acknowledgement that upon expiration the agency will demonstrate progress on electronic implementation (distribution and receipt) of this instrument.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2010	36 Months From Approved	04/30/2007
Responses	250,000	0	250,000
Time Burden (Hours)	62,500	0	62,500
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected by form SSA-3371 will be used to provide disability interviewers (and applicants/claimants in self-help situations) with a convenient means of recording the information. This information is used by the State Disability Determination Services (DDS) adjudicators, and administrative law judges, to assess the effects of symptoms on functionality for determining disability under the Social Security Act. The respondents are applicants for SSI benefits.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 75607	12/15/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 7809	02/20/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Pain Report - Child, 20 CFR 416.912 & 404.512	SSA-3371-BK	Pain Report-Child

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	250,000	250,000	0	0	0	0
Annual Time Burden (Hours)	62,500	62,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,540,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/26/2007

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