Disability Report-Appeal

Forms and Documents

Document Name	Status
Form SSA-3441-BK Disability Report-Appeal (Paper Version) Form and Instruction	Modified
Form SSA-3441-BK (EDCS Disability Report--Appeal (EDCS) Form	Modified
Addendum 02 01 10.doc Supplementary Document	2010-02-24
Supporting Statement revised 0144.doc Supporting Statement A	2010-06-25

IC Document Collections

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

ICR Details

OMB Control No: 0960-0144	ICR Reference No: 201002-0960-008
Status: Historical Active	Previous ICR Reference No: 200803-0960-003
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 without change	Conclusion Date: 09/16/2010
	Date Received in OIRA: 06/29/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	09/30/2010
Responses	1,272,962	0	1,463,908
Time Burden (Hours)	850,405	0	1,058,280
Cost Burden (Dollars)	0	0	0

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Abstract: SSA requires disability applicants who are appealing an unfavorable disability determination to complete Form SSA-3441-BK. This form allows claimants to disclose any changes to their disability or resources that might influence SSA’s unfavorable determination. SSA may use the information to: 1) reconsider and review an initial disability determination; 2) review a continuing disability; and 3) evaluate a request for a hearing. This information assists the State Disability Determination Services and administrative law judges (ALJs) in: 1) preparing for the appeals and hearings; and 2) issuing a determination or decision on an individual’s entitlement (initial or continuing) to disability benefits. Form SSA-3441-BK is available for the applicant to fill out and print, or submit via the internet. If the applicant fills out the paper form, they should bring into the field office (FO) when they have an appointment for an interview, or we may ask them to mail it to us ahead of time. If a telephone or face-to-face interview is completed, we will enter the information into the EDCS. Respondents are individuals who appeal denial, reduction, or cessation of Social Security disability income and Supplemental Security Income (SSI) payments, or who are requesting a hearing before an ALJ.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  

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:
	75 FR 9992	03/04/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 35512	06/22/2010
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)

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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	1,272,962	1,463,908	0	0	-190,946	0
Annual Time Burden (Hours)	850,405	1,058,280	0	0	-207,875	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: Overall, the burden for this collection has decreased since the last clearance cycle. The current figures, which represent a decrease in the paper and EDCS versions of the form, reflect our more accurate, updated information (previously, we had erroneously over-estimated the burden). Although there was an overall decrease in burden, there was an increase in the number of respondents using the Internet version. We expect this trend will continue as more people use the easier information technology methods.

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Annual Cost to Federal Government: $53,870

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]? No

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)? No

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: 06/29/2010

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