Work History Report

Forms and Documents

Document Name	Status
Form SSA-3369-BK Work History Report Form	Modified
SupportingStatement_3369_Final[1].doc Supporting Statement A	2007-07-23
ADDENDUM TO SUPPORTING STATEMENT.doc Supplementary Document	2007-07-10
PRA Statement.doc Supplementary Document	2007-03-22
ssa3369.pdf Supplementary Document	2007-02-15

IC Document Collections

IC ID	Document Title	Status
9542	Work History Report Form	Modified
181136	Work History Report (EDCS) Other-EDCS	New

ICR Details

OMB Control No: 0960-0578	ICR Reference No: 200702-0960-002
Status: Historical Active	Previous ICR Reference No: 200406-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Work History Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/07/2007
	Date Received in OIRA: 07/25/2007
Terms of Clearance: This ICR is approved on the understanding that SSA will, within the next 36 months and prior to renewal of this ICR, convene two focus groups of (a) disability adjudicators and (b) SSA claimants/benes. Anecdotal evidence suggests that claimants have difficulty with the parts of this form that ask them to break down their daily work activities by the hour (i.e. "in this job, how many total hours each day did you crouch, kneel, stoop," etc.). In turn, SSA adjudicators may need to follow-up with claimants to get the information they need because they could not obtain it through the form. The purpose of these focus groups will be to evaluate the utility of this question and to assess the extent to which utility could be improved. SSA agrees to ask adjudicators questions such as "how ofen is the information provided on this form incomplete, unreliable, or otherwise inadequate, requiring you to follow-up with the claimant to get the information required?" Questions to be asked of claimants include questions like "how easy or difficult do you find this question to answer?"

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	36 Months From Approved	12/31/2007
Responses	449,500	0	871,000
Time Burden (Hours)	449,500	0	871,000
Cost Burden (Dollars)	0	0	0

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Abstract: The SSA-3369-BK is used to document an applicant's work history. The information is used by Disability Determination Services (DDS) to make a decision about the alleged disability. The respondents are applicants for disability benefits.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: null
  

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:
	72 FR 12244	03/15/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 26443	05/09/2007
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Work History Report	SSA-3369-BK	Work History Report
Work History Report (EDCS)

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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	449,500	871,000	0	0	-421,500	0
Annual Time Burden (Hours)	449,500	871,000	0	0	-421,500	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The change in the SSA-3369 public burden hours since the last OMB Notice of Action (2004 OMB Approval) is based on data estimates that fewer respondents are using the paper form and the availability of EDCS 3369 data. Data collection for the EDCS 3369 didn’t begin until 2004. The SSA-3369 public reporting burden hours in Item #12 now includes the EDCS 3369 data. There have been no program changes and only minor revisions to this form since the last OMB approval on 06/10/04.

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Annual Cost to Federal Government: $18,158,700

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: 07/25/2007

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