SUPPORTING STATEMENT FOR FORM SSA-3371-BK
20 CFR 416.912, 404.512
OMB No. 0960-0540
A. Justification
1. Sections 1614 (a)(3)(H)(i) and 1631(e)(1) of the Social Security Act require that claimants for SSA benefits furnish medical and other evidence of disability as required to prove their disability. Disability regulations found in 20 CFR 416.912 and 404.512 state that an individual must provide medical evidence and, if asked, evidence of age, education, training, work experience, daily activities, efforts to work, and any other evidence showing how his or her impairment(s) affects the ability to work or, in the case of a child, how the claimant functions. Section 1631(d)(1) of the Act provides the Commissioner of Social Security with the full power and authority to make rules and regulations, establish procedures, and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same to evaluate the alleged disability.
Form SSA-3371-BK is used to provide disability interviewers (and applicants/claimants in self-help situations) with a convenient means to record information about the claimant’s pain or other symptom(s). This information is used by the State disability determination services (DDS) adjudicators and administrative law judges to assess the effects of symptoms on function for purposes of determining disability under the Social Security Act.
Form SSA-3371-BK is not currently scheduled for electronic implementation under the Agency’s Government Paperwork Elimination Act plan due to its low priority status and the Agency’s limited resources. However, this form will be examined in the future as a possible candidate for electronic implementation.
The nature of the information being requested, and the manner in which it is collected, preclude duplication. There is no other form in use by SSA which collects this information.
5. This collection does not have a significant impact on a substantial number of small businesses or other small entities.
6. The information and medical evidence collected by this form are the basis of the initial disability evaluation process. If this data were not collected, the Social Security Administration (SSA) could not discharge its mandate to pay benefits to disabled claimants, as it would be impossible to determine if claimants were truly disabled. The information could not be collected less often, as information must be gathered every time a claimant files for benefits. There are no technical or legal obstacles that prevent burden reduction.
7. There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.
The 60-day advance Federal Register Notice was published on December 15, 2006 at 71 FR 75607, and SSA received no public comments. The second Notice was published on February 20, 2007 at 72 FR 7809, and SSA received no public comments.
There have been no outside consultations with members of the public.
9. SSA provides no payment or gifts to the respondents.
10. 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. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.
11. The information collection does not contain any questions of a sensitive nature.
12. Approximately 250,000 respondents complete the SSA-3371-BK annually. The estimated time to complete this form is 15 minutes. Therefore, the total burden is 62,500 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $1,540,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. There are no changes to the public reporting burden.
The results of the information collected will not be published.
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.
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. Collections of Information Employing Statistical Methods
Statistical methods are not used for this information collection.
SSA-3371-BK
| File Type | application/msword |
| File Title | September 2000 |
| Author | John V Hailman |
| Last Modified By | Kathy |
| File Modified | 2007-02-20 |
| File Created | 2007-01-09 |