Disability Report-Appeal

Forms and Documents

Document Name	Status
Form SSA-3441-BK Disability Report-Appeal (Paper Version) Form	Modified
Form i3441 Disability Report--Appeal (Internet Version) Form and Instruction	New
Form SSA-3441-BK (EDCS Disability Report--Appeal (EDCS) Form	New
iAppeals Flow Chart.pdf Supplementary Document	2007-06-28
Revised and Deleted Questions from the i3441.pdf Supplementary Document	2007-06-28
SSA-3441 Current.pdf Supplementary Document	2007-05-16
Addendum--0144.doc Supplementary Document	2007-06-28
Supporting Statement--0144.doc Supporting Statement A	2007-06-28

IC Document Collections

IC ID	Document Title	Status
43698	Disability Report-Appeal (Paper Version) Form	Modified
180152	Disability Report--Appeal (Internet Version) Form and Instruction	New
180151	Disability Report--Appeal (EDCS) Form	New

ICR Details

OMB Control No: 0960-0144	ICR Reference No: 200705-0960-005
Status: Historical Active	Previous ICR Reference No: 200608-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report-Appeal
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: 08/22/2007
	Date Received in OIRA: 06/28/2007
Terms of Clearance: This ICR is approved consistent with changes made to the Welcome Screens for the iAppeals process which point out to the respondent the potentially wide differential in burden associated with the electronic form (versus the paper-based form) and provides the respondent with different ways to submit the information. To further minimize burden on the public, SSA should be thinking of ways to reduce the current 2 hour average burden associated with the iAppeals form between now and next submission.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	08/31/2009
Responses	1,463,908	0	1,112,720
Time Burden (Hours)	1,296,190	0	924,967
Cost Burden (Dollars)	0	0	0

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Abstract: The SSA-3441-BK is used to secure updated medical and other information since the claimant’s last disability determination from claimants who are appealing an unfavorable disability determination. This information may be used for reconsideration or request for federal reviewing official review of initial disability determinations and continuing disability reviews as well as a request for a hearing. This information assists the State Disability Determination Services, federal reviewing officials, and administrative law judges in preparing for appeals and hearings and in issuing a decision. Respondents are individuals who appeal denial of Social Security disability income and Supplemental Security Income (SSI) benefits, cessation of benefits, or who are requesting a hearing.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1383 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 14845	03/29/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 35293	06/27/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Disability Report--Appeal (EDCS)	SSA-3441-BK (EDCS Screens)	Disability Report--Appeal (EDCS Screens)
Disability Report-Appeal (Paper Version)	SSA-3441-BK	Disability Report--Appeal
Disability Report--Appeal (Internet Version)	i3441, i3441 (iAppeals)	Disability Report--Appeal ,   Disability Report--Appeal (i3441--Revisions to the Screening Questions for Use with the New iAppeals Program)

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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	1,463,908	1,112,720	0	0	351,188	0
Annual Time Burden (Hours)	1,296,190	924,967	0	0	371,223	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: The increase in the annual reporting burden is due to the fact that we have been able to compile more accurate data since we prepared the previous Supporting Statement for this information collection. The decrease which can be seen on the IC for the paper version of the SSA-3441-BK is due to the transition to ROCIS. In order to properly show the burden data for each version of this form, SSA had to add two more ICs in order to cover the other two versions of this form (Electronic Disability Collection System and Internet).

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Annual Cost to Federal Government: $14,287,941

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: 06/28/2007

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