Supporting Statement 0578

Supporting Statement for Form SSA-3369-BK

Work History Report

CFR 404.1512, 416.912, 404.1560, 404.1565, 416.960 and 416.965

OMB 0960-0578

1. Justification

1. Authoring Laws and Regulations: Sections 223(d)(5)(A) and 1631(e)(1) of the Social Security Act (Act) provide that claimants must furnish medical and other evidence to prove they are disabled. Implementing disability regulations at 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations state individuals must furnish medical evidence and, if asked, furnish evidence of age, education and training, work experience, efforts to work, and any other evidence showing how their impairment(s) affects their ability to work. 20 CFR 404.1560, 404.1565, 416.960, and 416.965 of the Code of Federal Regulations explain that under certain circumstances, the Social Security Administration (SSA) may ask claimants about work they have done in the past. If claimants cannot give us all of the information we need to make a determination, we will attempt to obtain, with their permission, the information from employers or other persons who may know the individuals’ work history, such as family members or co-workers. Sections 205(a) and 1631(d)(1) of the Act gives the Commissioner of SSA full power and authority to make rules and regulations, establish procedures, and adopt reasonable and proper rules as to the nature and extent of the evidence, as well as the methods of obtaining and evaluating such evidence, of an alleged disability.

2. Description of Collection: SSA uses Form SSA-3369-BK (Work History Report) to obtain the information specified in the regulations above. When claimants report having more than one job, we use Form SSA-3369-BK to obtain information about each of the jobs claimants have had in the 15 years prior to becoming unable to work. This form provides disability applicants, as well as third parties assisting the applicant, with a means of recording information about a claimant’s past work.

The information we collect on the SSA-3369 is used by state disability determinations service (DDS) adjudicators to evaluate vocational evidence as required at steps 4 and 5 of the disability determination sequential evaluation process.

3. Use of Information Technology to Collect the Information: SSA claims representatives use the electronic disability collect system (EDCS) to directly key in SSA-3369-BK information from applicants who report having only one job since the onset of their disability. We use the SSA-3369 paper form for applicants who have had more than one job.

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. Consequences of Not Collecting Information or Collecting It Less Frequently: The information we collect on this form is part of the evidentiary basis upon which we process the disability evaluation. This process is a 5-step sequential evaluation and work history is necessary at steps 4 and 5 of the process. If we did not collect the information, we would be unable to determine whether claimants were disabled. The consequence of not collecting this data would be that SSA could not discharge its mandate to pay benefits to disabled claimants. We only collect the information once and 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: SSA published the 60-day advance Federal Register Notice on August 3, 2010 at 75 FR 45692, and we received no public comments. We published the 30-day Notice on November 24, 2010 at 75 FR 71785. If we receive any comments on the second Notice, we will forward them to OMB. We did not consult with the public in the maintenance 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 is the breakdown of the burden hours for the paper SSA-3369 and EDCS.

Collection Method	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)
SSA-3369 (Paper form)	1,090,346	1	60	1,090,346
SSA-3369 (EDCS)	607,122	1	60	607,122
Totals	1,697,468			1,697,468

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 $24,672. This is the cost for processing and distributing the collection instrument and collecting the information. The estimated cost to the Federal Government to collect the information electronically is negligible. We account for the cost of maintaining the system that collects this information within the cost of maintaining all of SSA’s automated systems.

15. Program Changes or Adjustments to the Information Collection Request: The reason for the increase in the public burden is twofold. Economic downturn has dramatically increased the number of respondents since we last cleared this ICR. Secondly, we were inadvertently counting the respondents for this form under the electronic versions of the SSA-3368, Disability Adult, OMB #0960-0579 (i3368 Internet and EDCS 3368 collection methods).

16. 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- 3369, we 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 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.

For the EDCS SSA-3369, 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 information collection.