SupportingStatement_3369_Final[1]

Supporting Statement for Work History Report

CFR 404.1512, 416.912, 404.1560, 404.1565, 416.960 and 416.965

OMB 0960-0578

1. Justification

1. Authoring Laws and Regulations: Sections 223(d)(5)(A) and 1631(e)(1) of the Social Security Act, as amended, provide that claimants have to furnish such medical and other evidence as the Commissioner may require to prove that they are disabled. Implementing disability regulations at 20 CFR 404.1512 and 416.912 specifically state that an individual is to furnish medical evidence and, if asked, is to furnish evidence of age, education and training, work experience, efforts to work, and any other evidence showing how his or her impairment(s) affects the ability to work. 20 CFR 404.1560, 404.1565, 416.960 and 416.965 explain that under certain circumstances we will ask an individual about work he or she has done in the past. If the individual cannot give us all of the information we need, we will try with his or her permission to get it from the individual’s employer or other person who knows about his or her work, such as a family member or co-worker. Sections 205(a) and 1631(d)(1) of the Act give the Commissioner full power and authority to make rules and regulations, to 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.

2. How, by Whom and for What Purpose the Information Is to Be Used: Form SSA-3369 (Work History Report) is used to obtain some of the information specified in the regulations. When the individual has had more than one job, it supplements the SSA-3368 with detailed information about the jobs the applicant had in the 15 years prior to becoming unable to work. It provides disability applicants, as well as third parties assisting the applicant and Social Security Administration (SSA) interviewers in non-self-help situations, with a means of recording information about a claimant’s past work.

The information collected on the SSA-3369 is used by State disability determinations service (DDS) adjudicators to evaluate vocational evidence as required at steps 4 and 5 of the disability determination sequential evaluation process.

3. Use of Information Technology to Collect the Information: This information can be collected on the Internet via the Social Security Disability Report, which combines into one collection vehicle (i3368/69) the same information that is collected on paper forms SSA-3368 and SSA-3369. The i3368/69 form has a separate OMB clearance number, 0960-0579, and is not involved in this request for revision of the paper form. SSA claims representatives use EDCS to directly key in SSA-3369 information collected from applicants who have not used the Internet, have had more than one job.

3. Why Duplicate Information Cannot Be Used: 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. How Burden on Small Respondents Is Minimized: The collection of information does not involve small businesses or other small entities.

6. Consequences of Not Collecting Information or Collecting It Less Frequently: The information collected on this form, together with medical evidence, forms the evidentiary basis upon which the disability evaluation process is founded. This process is a 5-step sequential evaluation and work history is necessary at steps 4 and 5 of the process. If the information were not collected, it would be impossible to determine whether claimants were disabled. The consequence of not collecting this data would be that SSA could not discharge its mandate to pay benefits to disabled claimants.

7. Special Circumstances that Need to Be Explained: There are no special circumstances that would cause this information collection to be conducted in a manner that is not consistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public: The first Federal Register notice was published on March 15, 2007 at 72 FR 12244. There have been no comments from the public as a result of this notice. The second Federal Register notice was published on May 9, 2007 at 72 FR 26443.¹ There have been no outside consultations with members of the public.

9. Payment or Gifts to Respondents: SSA provides no payments or gifts to the respondents.

10. Assurances of Confidentiality: 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. Justification for Sensitive Questions: The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden: Listed below is the breakdown of the burden hours for the paper SSA-3369 and EDCS.

Collection Method	Number of Respondents	Frequency of Response	Average Burden Per Response	Estimated Annual Burden Hours
SSA-3369 (Paper form)	21,000	1	1 hour	21,000
EDCS 3369	428,500	1	1 hour	428,500
Totals	449,500			449,500

Note: There is no signature requirement for the paper or EDCS SSA-3369.

13. Annual Cost to the Respondents (Other): There is no known cost burden to the respondents.

14. Annual Cost to Federal Government: The annual cost to the Federal Government is approximately $18,158,700. This estimate includes projected printing and distribution costs ($161,700) for the paper form and the cost of collecting the information, and keying costs ($17,997,000) for the Electronic Disability Collect System (EDCS).

15. Program Changes or Adjustments to the Information Collection Budget: We do not have management information on how the estimated number of respondents was derived in 2004, when this ICR was last cleared. Since that time, we began collecting data on EDCS which provides monthly reports for each region nationwide. From these reports we can estimate the number of respondents for the upcoming year. Also, 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.

15. Plans for Publication of Results of Information Collection: The results of the information collection will not be published.

15. Request Not to Display OMB Expiration Date: 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.

15. Exceptions to Certification Statement: 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).

2. Collections of Information Employing Statistical Methods

Statistical methods are not used for this information collection.

1 The accurate public reporting burdens for this ICR are reflected in the 2^nd. FR. SSA inadvertently cited an incorrect number of respondents in the 1^st FRN.

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