SUPPORTING STATEMENT FOR FORM SSA-3371-BK
20 CFR 416.912, 404.512
OMB No. 0960-0540
A. Justification
1. Introduction/Authoring Laws and Regulations
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 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 the Social Security Administration (SSA) 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. The Social Security Administration (SSA) uses Form SSA-3371-BK to record information about pain or other systems of a child who is claiming disability.
Description of Collection
Disability interviewers and applicants/claimants in self-help situations use Form SSA-3371-BK to record information about pain or other symptoms of a child who is claiming disability. Self-help means the claimant completes the form rather than an interviewer completing the form by asking the claimant for the information that the form collects.
The State Disability Determination Services adjudicators and administrative law judges use this information to assess the effects of symptoms on functionality to help make a disability determination. SSA scans the information into the claimant’s electronic folder; there is no database for the information collected from the form. If the claimant does not have an electronic folder, the claimant's paper folder is used. The respondent can complete the paper form SSA-3371-BK. The respondents are applicants for SSI payments.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of form SSA-3371-BK under the agency’s Government Paperwork Elimination Act (GPEA) due to higher volume forms taking precedence. However, we will examine this form in the future as a possible candidate for electronic implementation.
Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
5. Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
6. Consequence of Not Collecting Information or Collecting it Less Frequently
The information and medical evidence collected by this form are the basis of the initial disability evaluation process. If we did not collect this information, we could not discharge our mandate to pay benefits to disabled claimants, as it would be impossible to determine if claimants were truly disabled. Since SSA collects this information every time a claimant files for benefits, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
SSA published the 60-day advance Federal Register Notice on November 17, 2009, at 74 FR 59336, and we received no public comments. The second Notice published on January 22, 2010, at 75 FR 3778. If we receive comments in response to the 30-day Notice, we will forward them to OMB. SSA did not consult members of the public in the development or maintenance of this form.
Note: This is a correction notice. SSA published this information collection as an extension on November 17, 2009, at 74 FR 59336. Since we are revising the Privacy Act Statement, this is now a revision of an OMB-approved information collection.
9. Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
10. Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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.
Estimates of Public Reporting Burden
Approximately 250,000 respondents take 15 minutes each to complete form SSA-3371-BK each year. Accordingly, the burden is 62,500 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
14. Annual Cost To Federal Government
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. Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
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).
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B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | September 2000 |
| Author | John V Hailman |
| Last Modified By | 666429 |
| File Modified | 2010-02-05 |
| File Created | 2009-11-30 |