Supporting Statement for Form SSA-3441-BK
Disability Report-Appeal
20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 422.140, 404.1713, 416.1513, 404.1740(b)(4), 416.1540(b)(4), and 20 CFR 405, Subpart C
0MB No. 0960-0144
A. Justification
Introduction/Authoring Laws and Regulations
Sections 205(a), 223 (d), and 1631(e) of the Social Security Act (Act), as well as 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations require individuals filing for Social Security or Supplemental Security Income (SSI) benefits based on disability to provide evidence showing how their impairment(s) affect their ability to work or function.
20 CFR 404.916(c) and 416.1416(c) state that SSA will include any new evidence applicants submit in connection with their request for reconsideration in this review.
Section 205(b) of the Act as well as 20 CFR 405, Subpart C and 20 CFR 422.140 requires the Social Security Administration (SSA) to provide a reconsideration of an initial denial at the State Disability Determination Services (DDS) level and an evidentiary hearing at the reconsideration appeal level for individuals who appeal an unfavorable disability determination. SSA denies the claim when we find the physical or mental impairment for which such benefits are payable to have ceased, not to have existed, or not to be disabling.
20 CFR 404.1713 and 416.1513, Mandatory use of electronic services, as well as 20 CFR 404.1740(b)(4) and 416.1540(b)(4) require a representative requesting direct fee payment to conduct business with us electronically at the times and in the manner we prescribe. This ICR accounts for the new requirement for these representatives to use iAppeals (see Addendum to the Supporting Statement for further explanation).
Description of Collection
SSA requires disability applicants who wish to appeal an unfavorable disability determination to complete the 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. The information SSA requests on the 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).
This information assists the State DDSs 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.
The 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 bring it 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 we complete a telephone or face-to-face interview with the applicant, we will enter the information into the Electronic Disability Collect System (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, or their representatives.
Use of Information Technology to Collect the Information
Currently, approximately 99% 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.
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.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
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 violate sections 221 (c) and (d) of the Act. Because we only collect the information once, 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
The 60-day advance Federal Register Notice published on December 1, 2011, at 76 FR 74838, and we received no public comments. SSA published the second Notice on January 31, 2012, at 77 FR 4857. 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.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
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
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 (minutes) |
Estimated Annual Burden (hours) |
SSA-3441-BK (Paper Form) |
5,604 |
1 |
45 |
4,203 |
Electronic Disability Collect System (EDCS) |
662,090 |
1 |
45 |
496,568 |
i3441 (Internet Form) |
605,268 |
1 |
28 |
282,458 |
Totals |
1,272, 962 |
|
|
783,229
|
The total burden for these IC instruments is 783,229 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
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.
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. In addition, the burden is changing due to the new electronic-use requirement (see Addendum for details).
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).
Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this IC instrument.
| File Type | application/msword |
| File Modified | 2012-01-31 |
| File Created | 2012-01-31 |