0058 Supporting Statement

Supporting Statement for Form SSA-824

Report on Individual with Mental Impairment

20 CFR 404.1513 and 20 CFR 416.913

OMB No. 0960-0058

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 223(d) and 1614(a) of the Social Security Act (Act) and Sections 20 CFR 404.1513 and 20 CFR 416.913 of the Code of Federal Regulations authorize Social Security Administration (SSA) adjudicators to collect information to determine if a claimant or applicant filing for disability benefits has an impairment that meets the severity and duration requirements of the law. SSA adjudicators use Form SSA-824, “Report on Individual with Mental Impairment,” to obtain evidence about claimants who have a mental impairment.

2. Description of Collection

The purpose of form SSA-824 is to obtain medical evidence from medical sources (i.e., respondents) who have treated, or are currently treating, the claimant for a mental impairment. SSA uses the information on this form to establish whether a claimant filing for disability benefits has a mental impairment that meets the statutory definition of disability in the Act. The respondents are individuals who are treating sources for claimants. Disability Determination Services (DDS) employees collect this information, usually on a one-time basis.

3. Use of Information Technology to Collect the Information

Due to low volume usage, SSA has not created an electronic version of the form in accordance with the agency’s Government Paperwork Elimination Act plan.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument that collects data similar to data we collect here.

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

Respondents may choose whether to complete this form. If the adjudicator does not use this form, he or she may need to use other more costly methods, e.g.., consultative examinations, to obtain the evidence necessary to evaluate disability claims involving mental impairments. 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 1, 2011 at 76 FR 45902. We did not receive any public comments. We published the second Notice on November 7, 2011 at 76 FR 68805. If we receive any comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with members of the public in the maintenance of this form.

9. Payment or Gifts to Respondents

SSA pays non-Federal respondents for the reasonable cost of providing the information, as required by sections 223(d)(5)(A) and 1614(a)(3)(H)(i) of the Act and 20 CFR 404.1514 and 416.914. SSA does not provide any gifts to respondents.

9. Assurances of Confidentiality

SSA protects and holds confidential the information we collect 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.

9. Justification for Sensitive Questions

The information we collect is sensitive because it relates to psychological problems and disorders of the claimant. However, because adjudicators cannot make a disability determination for a mental impairment without collecting this evidence, it is essential that we make every reasonable effort to obtain it. If the respondent does not reply, we must look to other sources for evidence (e.g., consultative examinations).

9. Estimates of Public Burden

The estimated total number of respondents is 500. We estimate that half are individual treating sources and half are mental health facilities. The estimated response time is 36 minutes. Thus, the estimated total annual burden for this information collection is 300 hours.

Type of Respondents	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
Individuals responding as treating sources	250	1	36	150
Mental Health Facilities	250	1	36	150
Totals	500	-	-	300

9. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

9. Annual Cost to the Federal Government

We estimate the Federal Government pays an average of $15 to respondents for medical evidence of record. Therefore, the estimated annual cost to the Federal Government to collect the information is $7,500.

9. Program Changes or Adjustments to the Information Collection Request

Since last we cleared this information collection, the DDS offices have changed their business processes for acquiring this information. They have found it more cost effective to use the medical evidence of record process as outlined in the OMB-approved information collection OMB No. 0960-0555, Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of the Social Security Administration.

9. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

9. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to display the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. 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 useable editions with expired OMB approval dates. We avoid Government waste because we will not need to destroy and reprint stocks of forms.

9. Exceptions to Certification statement

SSA does not request an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.