Supporting Statement--0144

Supporting Statement for Form SSA-3441-BK

Disability Report-Appeal

20 CFR 404.1512 & 416.912, 20 CFR, 404.916(c) & 416.1416(c), and 20 CFR 405, Subpart C & 20 CFR 422.140

0MB No. 0960-0144

A. Justification

1. Title II, Sections 205(a), 223 (d) and Title XVI, Section 1631(e) of the Social Security Act (the Act), as well as 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations require that an individual filing for Social Security or Supplemental Security Income (SSI) benefits based on disability must provide evidence which shows how the claimant’s impairment(s) affect his or her ability to work or function. Additionally, 20 CFR 404.916(c) and 416.1416(c) state, “Any new evidence you submit in connection with your request for reconsideration will be included in this review.”

In addition, Section 205(b) of the Act as well as 20 CFR 405, Subpart C and 20 CFR 422.140 require that the Social Security Administration (SSA) provide a reconsideration or review by a Federal reviewing official (FedRO) of the determination on an initial claim; and an evidentiary hearing at the reconsideration appeal level for individuals when the physical or mental impairment for which such benefits are payable is found to have ceased, not to have existed, or not to be disabling. The information requested on Form SSA-3441-BK facilitates collecting medical information to support the individual’s request for reconsideration; request for FedRO review; benefits cessation appeal; and request for hearing before an administrative law judge (ALJ) based on disability.

2. SSA requests that an individual complete this form for reconsideration or review by a FedRO of Social Security Disability Insurance and SSI disability claims following a previous denial; a reconsideration of cessation of disability benefits; and when requesting a hearing before an ALJ. SSA uses this form to secure updated information on the individual’s sources and condition. This information assists the State disability determination services, FedROs, and ALJs in preparing for the appeals and hearings and in issuing a decision on whether or not an individual is entitled to, or continues to be entitled to, disability benefits. Respondents are applicants for reconsideration or review by a FedRO of initial denial of disability benefits; reconsideration of disability cessation; and/or individuals requesting a hearing before an ALJ.

3. Currently, approximately 98.5 percent of the total responses are collected through either SSA’s Electronic Disability Collection System (EDCS) screens or via an Internet version of this form; and only 1.5 percent of the respondents use the paper version.

4. 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. This collection does not have an impact on small businesses or other small entities.

6. If this information were not collected, individuals would be deprived of the right to present evidence pertaining to their appeal, and statutory and regulatory requirements relating to due process would be violated. Therefore, it cannot be collected less frequently. 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 that is not consistent with 5 CFR 1320.5.

8. The 60-day advance Federal Register Notice was published on March 29, 2007 at 72 FR 14845, and SSA has received no public comments. The second Notice was published on June 27, 2007, at 72 FR 35293. 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. Listed below for FY 2006 is a breakdown of the burden hours associated with each collection method. All respondents are individuals.

Collection Method	Number of Respondents	Frequency of Response	Average Burden Per Response:	Estimated Annual Burden Hours
SSA-3441-BK (Paper Form)	21,282	1	45-minutes	15,962
Electronic Disability Collect System (EDCS)	1,284,019	1	45-minutes	963,014
i3441 (Internet Form	158,607	1	120-minutes	317,214
Totals	1,463,908			1,296,190

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.

13. The annual cost to the Federal government is approximately $14,287,941. This estimate is a projection of printing and distribution costs for the paper form and the cost of collecting the information. It also includes keying costs for the Electronic Disability Collect System.

13. 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).

13. The results of the information collection will not be published.

17. 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.

18. 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 for the collection of information are not used.

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