Supporting Statement revised 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. Introduction/Authoring Laws and Regulations

Sections 205(a), 223 (d) and 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 provide evidence that shows how the applicant’s impairment(s) affect their ability to work or function.

20 CFR 404.916(c) and 416.1416(c) states that any new evidence the applicant submits in connection with their request for reconsideration will be included in this review.

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 of an initial denial at the State disability determination services level, 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 applicant’s request for reconsideration; request for benefits cessation appeal; and request for a hearing before an administrative law judge (ALJ).

2. Description of Collection

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.

3. Use of Information Technology to Collect the Information

Currently, approximately 99 percent of the total responses either are collected through EDCS screens or via an Internet version of this form (i3441); and only 1 percent of the responses are collected via the paper version.

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of form SSA-3441. Based on our data, we estimate approximately 33 % of respondents under this OMB number use the electronic version, i3441.

4. 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

If we did not use Form SSA-3441-BK, the public would have no way to apply for reconsideration, benefits cessation appeal, or for a hearing before an ALJ. This would be a violation the Social Security Act, Section 221 (c) and (d). Because we only collect the information once, we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

7. 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.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on March 04, 2010, at 75 FR 9992, and we received no public comments. SSA published the second Notice on June 22, 2010, at 75 FR 35513. If we receive comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

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.

12. Estimates of Public Reporting Burden

Listed below for FY 2009 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)	12,604	1	45-minutes	9,453
Electronic Disability Collect System (EDCS)	843,090	1	45-minutes	623,318
i3441 (Internet Form)	417,268	1	30-minutes	208,634
Totals	1,272, 962			841,405

The total burden for these IC instruments is 1,467,307 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.

13. Annual Cost to Federal Government

The annual cost to the Federal Government is approximately $53,870. This estimate is a projection of the cost for printing and distributing the collection instrument.

13. Program Changes or Adjustments to the Information Collection Request

Overall, the burden for this collection has decreased since the last clearance cycle. These updated 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.

13. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-3441-BK, SSA will not publish 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 the OMB approval date. Since SSA does not periodically (e.g., on an annual basis), revise and reprint its public-use forms, OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, thereby avoiding Government waste.

For the electronic versions of Form SSA-3441-BK, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. 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

SSA does not use statistical methods for this IC instrument.