Disability Report - Adult

Forms and Documents

Document Name	Status
Form SSA-3368 Disability Report - Adult, (Paper Version) Form and Instruction	Modified
Addendum - 0579.docx Supplementary Document	2012-08-09
Supporting Statement - 0579.docx Supporting Statement A	2012-08-09

IC Document Collections

IC ID	Document Title	Status
9548	Disability Report - Adult, (Paper Version) Form and Instruction	Modified
179421	Disability Report - Adult, (i3368PRO) Other-i3368 PRO	Removed
179420	Disability Report - Adult, (Internet Version) Other-SSA-3368 (Internet)	Modified
179419	Disability Report - Adult (EDCS Version) Other-EDCS	Modified

ICR Details

OMB Control No: 0960-0579	ICR Reference No: 201205-0960-003
Status: Historical Active	Previous ICR Reference No: 201104-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report - Adult
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: 09/27/2012
	Date Received in OIRA: 08/13/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	36 Months From Approved	11/30/2012
Responses	3,303,724	0	2,592,034
Time Burden (Hours)	3,514,337	0	2,757,163
Cost Burden (Dollars)	0	0	0

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Abstract: State Disability Determination Services (DDS) use the SSA–3368 and its electronic versions to determine if an adult disability applicant's impairment(s) is severe and, if so, how the impairment(s) affects the applicant's ability to work. This determination dictates whether the DDSs and SSA will find the applicant to be disabled. Therefore, the information the DDSs collect on this form is crucial in making disability determinations for all adult claimants filing for SSA disability benefits or Supplemental Security Income (SSI) payments. The respondents are applicants for title II disability benefits or title XVI SSI payments.

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Authorizing Statute(s): US Code: 42 USC 205(a) Name of Law: The Social Security Act
   US Code: 42 USC 223(d)(5)(A) Name of Law: The Social Security Act
   US Code: 42 USC 1631(e)(1) Name of Law: The Social Security Act
   US Code: 42 USC 1631(d)(1) Name of Law: The 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:
	77 FR 29441	05/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47688	08/09/2012
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 - Adult (EDCS Version)
Disability Report - Adult, (Internet Version)
Disability Report - Adult, (Paper Version)	SSA-3368	Disability Report - Adult -- Revised Version
Disability Report - Adult, (i3368PRO)

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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	3,303,724	2,592,034	0	0	711,690	0
Annual Time Burden (Hours)	3,514,337	2,757,163	0	0	757,174	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: We discontinued the i3368-PRO upon full implementation of the revised i3368 Internet application as promised in our last full information collection request. The i3368 absorbs the former i3368-PRO users. We successfully completed full implementation of the i3368 as promised in our last request. In addition, we periodically update the dollar amount for monthly gross earnings in questions on the paper form (See Addendum for more information).

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Annual Cost to Federal Government: $35,958,328

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]? No

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: 08/13/2012

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